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Y4 - GOSH > Antepartum Haemorrhage > Flashcards

Antepartum Haemorrhage Flashcards

1
Q

definition of Placenta Praevia

A

placenta developing within the lower uterine segment with a close distance between the lower placental edge and internal os of the cervix

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2
Q

what is considered a low lying placenta

A

placental edge within 20 mm of internal os

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3
Q

what is considered a normal placenta position

A

placental edge stary more than 20 mm away from the internal os

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4
Q

what is the pathophysiology of placenta praevia

A

the placenta develops from discoid trophoblast, the position of placenta depends on the implantation of discoid trophoblast.

in normal pregnancy, the placenta usually migrate away from the internal os, but sometimes this does not occur due to mal-implantation of the discoid trophoblast being lower than usual

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5
Q

how common is placenta praevia

A

5-28% of pregnancy in 2nd trimester

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6
Q

Risk factor for placenta praevia

A

advanced maternal age
smoker
artificial reproductive method
prev C/S - inc risk of implantation of discoid trophoblast on the C/S scar

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7
Q

what is the self-made story that reminds me of the risk factors for placenta praevia

A

An older woman who smokes has a kid with her 3rd husband after previous C/S through IVF.

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8
Q

what are the investigations for placenta praevia

A

1) foetal anomaly scan at 20 wks - part of the normal USS scan –> if low lying/placenta praevia –> F/U USS + TVS scan at week 32

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9
Q

what does short cervical length inc risk of?

A

inc risk of emergency C/S and massive haemorrhage at C/S

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10
Q

what are the symptoms of placenta praevia

A

painless PV bleed that has bright red blood - still oxygenated

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11
Q

what are some management of placenta praevia

A

advise contacting pregnancy service if contraction starts, bleeding

steroid for baby between 34 and 35 weeks

C/S for any Type 3 or more severe placenta praevia
- vaginal delivery can be attempted but only if marginal/minor praevia

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12
Q

in what conditions will you want to deliver a baby before 37 weeks with placenta praevia

A

if foetal contractions can not be suppressed
if severe bleeding
if IUGR
if IUD

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13
Q

what is type 1 placenta praevia

A

placental edge within 20mm of the internal os

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14
Q

what is type 2 placenta praevia

A

marginal - when the placental edge is very close to internal os but still not cross the internal os

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15
Q

what is type 3 placenta praevia

A

partial - when parts of the placenta cross/ in the middle of the internal os

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16
Q

what is type 4 placenta praevia

A

complete - when the internal os is in the middle of the placenta

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17
Q

what is placental abruption

A

premature seperation of normal sited placenta from uterus

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18
Q

what is the potential aetiology of placental abruption

A

acute inflammation + chronic vascular dysfunction

inflammation process mediate by cytokines (produces matrix metalloproteinese) which casues destruction of extra-cellular matrix & disruption of cell-cell membrane - ie abruption

blood then tracks down the uterus between the membranes & uterine wall–> further seperation

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19
Q

how can planetal abruption cause PPH

A

if degree of bleeding is large - large pressure generated in the uterus - blood extend into the myometrium - rupture internally & so blood can affect contraction - PPH

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20
Q

what are the RF/causes of placental abruption

A

○ Folic acid deficiency –> essential for development of placenta vascular bed
○ Cocaine –> can cause vasoconstriction and disrupt placenta adherence
○ Smoking
○ PIH/PET –> Pregnancy induced hypertension/Pre-eclampsia toxaemia
○ Thrombophilia - inc inflammatory makers?
○ Premature rupture of membranes –> presence of inflammation + infection
○ Multiple pregnancy –> sudden uterus decompression after delivery of first twin
○ Trauma
Recurrence

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21
Q

symptoms of placental abruption

A 
PV bleed 
constant abdo pain 
utrine tenderness & woody sensation 
shock symptoms maternally 
DIC - bleeding from drip site/skin bruising
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22
Q

investigation for placental abruption

A

Bloods - FBC, U&es, LFT, G&S (X-match 4-6 units of blood)

Check for HELLP Syndrome

Coag, prothrombin time/activated partial thromboplastin time

fibrinogen level (pregnanct assoicated with hyperfibrinogenaemia & so even modestly dec fibrinogen may show severe coagulopathy – < 200 = severe abruption

Kleihauer- Bettle Test - to detect foeta blood cells in maternal circulation (also helps to correctly dose Anti-D)

USS - to assess blood inuterus or not

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23
Q

mx of placental abruption

A

if near term + foetus stable - induction by ARM & syntocinon infusion for vaginal delivery

IF FOETAL COMPROMISE - C/S

24
Q

how do you screen for placenta abruption

A

uterine artery doppler - vascualr dysfunction leads to reduced invasion of cytotrophoblast & is assoicated with inc risk of placenta abruption

25
Q

definition of placenta accreta

A

abnormally invastive placentation that can be categorised by depth

26
Q

what layer of invasion does placenta accreta involve?

A

choriic villi attach to the myometrium in the abscence of decidua

27
Q

what layer of invasion does placenta increta involve?

A

deepper into the myometrium but not extend to the outmost laters of uterus

28
Q

what layer of invasion does placenta percreta involve?

A

through the myometrium up to the serosa

29
Q

RF for placenta accreta

A

placenta praevia - implantation problem

prev C/S - decidua basails, a layer that prevents the invasion of trophoblasts cell penetrate deeper into the myometrium - can be damaged due to prev C/S

30
Q

Ix for placenta accreta

A

USS

MRI - to help with the depth of invasion and lateral extension of myometrial invasion

31
Q

what would make you be suspous of placenta accreta

A

previous C/s + anterior placenta praevia

32
Q

Mx of placenta accreta

A

elective admisison from 34 wks + antenal corticosteriods at wk 34 + C/S

33
Q

what is the risk of C/S hysterectomy if a woman has placenta praevia & prev C/S

A

27/100

34
Q

definiton of vasa praevia

A

when the foetal vessels (not umbilical cord) crossing the internal os through the free placental membrane

35
Q

what are the different types of vasa praevia

A

type 1/velamentous - occurs secondary to celamenotus (veli-like) cord insertion - 90%

type 2/succenturiate - occurs when foetal vessels connect lobes of placenta - 10%

36
Q

what are the RF for vasa praevia

A

IVF - not naturally implanted & so can implant wrongly

placenta praevia/low-lying placenta

37
Q

how is vasa praevia diagnosed

A

detected intrapartum during vaginal exam to fidn the cord to be in the membrane

USS - diagnosed in 2nd trimester - 20% resolve prior to delivery

38
Q

Mx of vasa praevia?

A

prophylactic admission nfrom 30-32 wks + corticosteriods from wk 32 + elevative C/S at 34-36 weeks

39
Q

what is uterine rupture

A

full thickness loss of the uterine wall and visceral peritoneum

40
Q

in what circumstance would uterine rpture most likely to occur

A

during 2nd stage of labour + prev C/S/ prev abdominal surgery

41
Q

what are the risk factors of uterine rupture

A

1) prev C/s
2) IOL
3) AOL
4) hyperstimulation
5) inc parity
6) malpresentation - eg breech
7) abnor uterus - eg biconcave
8) macrosomia
9) trauma/RTA

42
Q

sign and symptoms of uterine rupture

A

1) can have no signs and symptoms at all - mother can compensate
2) pain between contraction
3) RFM esp during 2nd stage of pregnancy
4) haematuria & blood stain liqour
5) CTG abnor

43
Q

mx of uterine rupture

A

stabilisation of mother and emergency C/S

44
Q

what is placenta accreta

A

placenta moribidly attached to the uterine wall to an inc degree

degree dependent conditions - accreta, increta, percreta

45
Q

what is the highest rate of complication for placenta accreta

A

the retained placenta which might require surgical management

higher risk of PPH

aslo assocaite with per-term labour

46
Q

management of placenta accreta

A

elective C-section from 34 weeks + antenatal steriods

hysterectomy is highly likely

47
Q

which layer of muscle is placenta accreta attach to

A

directly to the myometrium in the absence of decidua

48
Q

which layer of muscle is placenta increta attach to

A

placental villi invade deeper into the myometrium, but do not extend to the outermost layers of the uterus.

49
Q

which layer of muscle is placenta percreta attach to

A

chorionic villi penetrate through the myometrium up to the serosa.

50
Q

ix for placenta accreta

A

Antenatal diagnosis
Prev C/S + anterior placenta previa  suspicious

Imaging
USS
MRI; helps with depth of invasion and lateral extension of myometrial invasion

Diagnostic value of both have been found to be similar

51
Q

what is vasa previa

A

fetal vessels crossing the internal cervical os through the free placental membranes

vasa praevia is likely to rupture during active labour or iatrogenically with artificial rupture of membranes

Can lead to fetal haemorrhage, exsanguinationand death

52
Q

what are the different types of vasa previa

A

type 1
occurs secondary to a velamentous cord insertion (90% cases)

type 2
occurs when fetal vessels connect lobes of a placenta, for example when a succenturiate lobe is present. (10% cases).

53
Q

risk factor for vasa previa

A

IVF

54
Q

how do you diagnose vasa previa

A

occasionally detected intrapartum during vaginal examination when vessels are felt in the membrane
USS

Vasa praevia diagnosed in the second trimester resolves in approximately 20% of patients prior to delivery, therefore a repeat scan at 32 weeks is warranted.

55
Q

management of vasa previa

A

prophylactic hospitalisation from 30–32 weeks should be considered

Elective delivery via caesarean at 34–36 weeks with a course of antenatal steroids from 32 weeks is reasonable in an asymptomatic patient.

If there is bleeding from a known or suspected vasa praevia, especially with suspected fetal compromise, delivery should be immediate and usually by caesarean section category 1

Y4 - GOSH (12 decks)

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