Antepartum Haemorrhage

Question 1

whats the definition of antepartum haemorrhage

Answer 1

Bleeding from the genital tract after 24 weeks gestation

Question 2

what is placental praevia

Answer 2

when the placenta implants in the lower part of the uterus,

Question 3

at which point is a low lying uterus considered placental praevia

Answer 3

persistence beyond 20 weeks gestation as it is normal at this point but it should move by term

Question 4

what is the classification of placental praevia

Answer 4

minor - lower segment of uterus, away from internal os

major - partially or totally covering the os

Question 5

what is the aetiology of placental praevia

Answer 5

Majority Unknown

Twins

High parity

Scarred uterus

Increased maternal age

Question 6

how may placental preavia affect the labour mechanism

Answer 6

it may prevent engagement necessitating a C-section

Mass effect may cause a transverse lie

may be a cause of massive antepartum haemorrhage

Question 7

what is placental accreta

Answer 7

deep implantation of the placenta into a uterine scar, usually a c-section scar, leading to difficulty separating from the uterus

Question 8

what is placental percreta

Answer 8

invasion of the placenta through the uterine wall into other structures

Question 9

what % of patients with a previous C section + placental praevia get placental accreta

Answer 9

10%

Question 10

whats the presentation of placental praevia

Answer 10

painless antepartum haemorrhage

increases in frequency and intensity over weeks

1/3 do not bleed before delivery

abnormal lie/presentation common

Question 11

how do you diagnose placental praevia

Answer 11

USS

2nd trimester scan may detect a low lying placenta

There is a repeat scan at 32 weeks to confirm placental praevia

Placenta <2cm from internal os is likely to be praevia at birth, and if the placenta is anterior then a 3D power USS is used to exclude placenta accreta

Question 12

what investigations do you do if placental praevia is diagnosed

Answer 12

CTG

FBC

Clotting

Cross match

Question 13

how do you manage placental praevia

Answer 13

Antepartum haemorrhage suspected to be praveia = admit

If <34 weeks steroids are administered

Delivery by elective C-section at 39 weeks

Emergency C section is required is severe bleeding before

Placenta accreta or percreta must be identified earlier on and a clear plan must be made for elective delivery supported by interventional radiology and surgeons

Question 14

what is placental abruption

Answer 14

partial or total separation of the placenta from the uterus

Question 15

what are the consequences of placental abruption

Answer 15

further separation

foetal distress

massive antepartum haemorrhage

foetal death (30%)

DIC/Renal failure in mother

Question 16

what are risk factors for placental abruption

Answer 16

IUGR

Pre-eclampsia

Cocaine use

Maternal smoking

Autoimmune disease

Previous history of placental abruption

Multiple pregnancy

High maternal parity

Trauma

Sudden reduction in uterine volume

Question 17

what is the common presentation for placental aburption

Answer 17

painful bleeding with dark blood

Question 18

what are signs of deterioration in a patient with placental abruption

Answer 18

tachycardia

hypotension

Question 19

how is placental abruption diagnosed

Answer 19

clinical diagnosis

Question 20

how do you manage placental abruption

Answer 20

Admission required

Delivery – depending on foetal state and gestation

If the foetus is distressed the emergency C section

Otherwise labour is induced by amniotomy (artificial rupture of the membranes)

If no foetal distress and the abruption is minor and the pregnancy is preterm, steroids can be used and the woman monitored, if all symptoms are gone discharge is allowed

Any episode of abruption where delivery is not undertaken causes reclassification of the pregnancy to high risk, due to the much higher risk of post-partum haemorrhage

Maternal ICU may be necessary

Question 21

what is a ruptured vasa praevia

Answer 21

the foetal blood vessel runs in the membranes in front of the presenting part, this usually results in the umbilical cord being attached to the membranes rather than the placenta

Rupture is more likely with vessels closer to the cervix

Question 22

what is the typical presentation of a ruptured vasa praevia

Answer 22

Painless, moderate vaginal bleeding occuring around the time of the rupture of the membranes

Accompanied by severe foetal distress

High mortality – foetus does not often survive to c-section