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Obs&Gynae > Antepartum hemorrhage > Flashcards

Antepartum hemorrhage Flashcards

1
Q

what is the triad of maternal mortality

A
  • sepsis
  • hypertension (pre eclampsia/ eclampsia)
  • obstetric hemorrhage
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2
Q

What are the key risk factors for obstetric haemorrhage? (6)

A
  1. Abnormal placentation (e.g., placenta previa, placenta abruption, ectopic pregnancy).
  2. Birth canal injuries (e.g., Forceps/vacuum delivery, Caesarean delivery).
  3. Obstetric factors (e.g., previous postpartum haemorrhage, preeclampsia/eclampsia).
  4. Vulnerable patients (e.g., chronic renal insufficiency).
  5. Uterine atony (e.g., uterine over-distension, multiple fetuses, hydraminos).
  6. Coagulation defects (e.g., HELLP, massive transfusions, prolonged retention of dead fetus).
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3
Q

How is antepartum haemorrhage defined?

A

Antepartum haemorrhage refers to bleeding from the genital tract at >28 weeks gestation, at any time prior to delivery

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4
Q

What is the initial approach to managing antepartum haemorrhage? (8)

A
  1. Call for help and mobilize staff.
  2. Evaluate patients general condition quickly including vital sign check.
  3. IV access with 2 large bore cannulae. (16G)
  4. Foley catheter placement to monitor input and output.
  5. Maintain SBP>100 mmHg and UOP>30ml/hr (give minimum of 0.9% NS 1Lrapid infusion while awaiting blood products)
  6. Send blood for FBC, U&Es, Cr, clotting time, and cross-matching.
  7. Order 2 units each of packed red blood cells, fresh frozen plasma, or whole blood if heavy bleeding.
  8. Perform an ultrasound scan to determine fetal condition and rule out placenta previa or evaluate for possible placenta abruption where present
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5
Q

What are the primary causes of antepartum haemorrhage? (4)

A
  1. Abnormal placentation (e.g., placenta previa, placental abruption).
  2. Uterine rupture.
  3. Fetal causes (e.g., vasa previa).
  4. Maternal causes (e.g., genital tract tumors, varicosities, trauma, local cervical/vaginal infections).
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6
Q

What is placenta previa

A

is when the placenta develops wholly or partly over the internal cervical os, causing painless 3rd trimester bleeding.

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7
Q

how do you classify placenta previa

A
  1. Minor:
    I. Low-lying placenta: Placenta encroaches the lower uterine segment but does not reach the internal Os.
    II. Marginal: Placenta reaches the internal Os but does not cover it.
  2. Major:
    III. Partial: Placenta partially covers the internal Os.
    IV. Complete: Placenta completely covers the internal Os.
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8
Q

How is placenta previa managed depending on severity and gestational age? (4)

A
  1. Heavy APH with confirmed previa at ≥28 weeks: Prepare for Caesarean delivery.
  2. Minimal/moderate APH and preterm:
    - Admit to the Antenatal Ward, transfuse as needed depending on Hb
    - maintain IV access with large bore cannula
    - administer steroids if GA <34 weeks.
    - Obstetric USS
  3. No APH with placenta previa found on routine US:
    - at GA ≥28 weeks admit to antenatal ward and give a course of dexamethasone
    - Plan for elective Caesarean delivery between 36-37 weeks of gestation.
  4. Be prepared for PPH and placenta accreta/ increta if previous scar. Prepare blood products and counsel about possible hysterectomy
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9
Q

What is placental abruption

A

Placental abruption occurs when the placenta separates partly or completely from the uterus before delivery, leading to blood accumulation behind the placenta.

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10
Q

what are the types of placental abruption (2)

A
  1. Concealed: Blood is trapped behind the placenta.
  2. Revealed: Blood is lost via the cervix.
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11
Q

How is placental abruption managed? (4)

A
  1. Check fetal heart and cervical exam:
    - if fetal heart is present and its a viable fetus (EFW>1000g or EGA >28weeks) then deliver immediately via c/s
    - if absent fetal heart, then consider vaginal delivery (IOL if applicable)
    - if heavy bleeding and remote from vaginal delivery or high risk of maternal mortality then c/s regardless of fetal status
  2. Be prepared for PPH (have oxytocin and misoprostol ready) and anticipate need for condom balloon tamponade
  3. If concomitant HTN then manage fluid balance with care (risk of pulmonary edema with increased intravascular volume)
  4. If heavy bleeding, organize at least 2 units each of PRBC, FFP, and platelets or whole blood.
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12
Q

What is uterine rupture

A

is a full-thickness disruption of the uterine wall, often life-threatening,
and occurs often in the 3rd trimester.

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13
Q

What is vasa previa

A

is a condition where fetal blood vessels traverse the fetal membranes over or near the internal cervical os, unprotected by the placenta or umbilical cord.

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14
Q

What are the risks of vasa previa (4)

A
  1. These vessels are at risk of rupture when the membranes rupture.
  2. Rupture can lead to rapid fetal exsanguination (severe blood loss) and is a life-threatening emergency for the fetus. (pale newborn)
  3. It is associated with a high perinatal mortality rate if not diagnosed antenatally.
  4. fetal vessels can be compressed causing asphyxiation
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15
Q

How is vasa previa diagnosed/ signs of vasa previa (4)

A
  1. Antenatal Ultrasound: Transvaginal ultrasound with color Doppler is the gold standard for diagnosing vasa previa.
  2. Clinical Signs: During labour, it may present as painless vaginal bleeding with rupture of membranes
  3. fetal distress.
  4. Speculum: Presence of fetal blood vessels crossing over or near the cervical opening(confirms diagnosis)
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16
Q

How is vasa previa managed (4)

A

Goal is to prolong the pregnancy while planning for an early delivery to minimize risks:
1. Scheduled Cesarean Delivery(34 and 37 weeks of gestation, to prevent the rupture of blood vessels during labor
2. Corticosteroids: Mature baby’s lungs if early delivery is anticipated.
3. Increased Monitoring: Hospitalize for close monitoring If there are additional risk factors or symptoms like vaginal bleeding or contractions.
4. Pelvic Rest: Avoiding sexual intercourse and inserting anything into the vagina to reduce the risk of complications.

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17
Q

what is placenta accreta

A

The placenta attaches too deeply into the uterine wall but does not penetrate the muscle (myometrium).

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18
Q

What is placenta increta

A

The placenta invades the myometrium (uterine muscle) but does not penetrate the entire thickness of the uterine wall.

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19
Q

What is placenta percreta

A

The placenta penetrates through the entire uterine wall, potentially invading nearby organs such as the bladder.

20
Q

How is placental abruption classified? (3)

A

Grade 1 (Mild):
1. Symptoms: Vaginal bleeding with or without mild uterine tenderness.
2. Fetal status: Fetal heart rate usually normal.
Grade 2 (Moderate):
1. Symptoms: Moderate vaginal bleeding, uterine tenderness, and contractions.
2. Fetal status: Fetal distress, evidenced by abnormal fetal heart rate.
3. Maternal status: Signs of maternal hypovolemia.
Grade 3 (Severe):
1. Symptoms: Severe vaginal bleeding or concealed hemorrhage, significant uterine tenderness.
2. Fetal status: Fetal death.
3. Maternal status: Maternal shock, disseminated intravascular coagulation (DIC), risk of renal failure, possible Couvelaire uterus (blood penetrates uterine muscle).

21
Q

What are the risk factors of uterine rupture (5)

A
  1. Previous uterine surgery (e.g., Caesarean section).
  2. Uterine overdistension (e.g., multiple pregnancies, polyhydramnios).
  3. Induction or augmentation of labour.
  4. Trauma.
  5. Congenital uterine anomalies.
22
Q

What things from history and exam are significant for uterine rupture? (8)

A
  1. vaginal bleeding
  2. abdominal pain or free fluid
  3. abnormal contour
  4. tender abdomen
  5. easily palpable fetal parts
    6.+/- absent fetal movements
  6. +/- absent fetal heart sounds
  7. possible shock from hypovolemia/ APH
23
Q

How is uterine rupture managed? (6)

A
  1. Emergency laparotomy. Repair the rupture if possible, if not then hysterectomy.
  2. In cases of uterine repair counsel the patient that all subsequent deliveries are to be c/s. Counsel the patient to seek early antenatal care at central hospital
  3. document operative findings in health passport.
  4. Resuscitation with IV fluids and blood products.
  5. Prepare for possible massive transfusion.
  6. Postoperative Care:
    - Intensive monitoring.
    - Address potential complications (e.g., infection, coagulopathy).
24
Q

what the risk factors for placenta previa (5)

A
  1. advanced maternal age
  2. multiparity (multiple gestation)
  3. prior cesarian section
  4. uterine instrumentation
  5. previous previa
25
Q

what can placenta previa complicate into

A

placenta accreta, increta and percreta

26
Q

in the presence of placenta previa, the risk of acreta increases due to what

A

number of previous c-sections

27
Q

what is the risk of number of c-sections + placenta previa in developing accreta (4)

A

1 c-section + previa= 3% risk of accreta
2 c-sections + previa = 10% risk of accreta
3 c-sections + previa = 40% risk of accreta
4 c-sections + previa= 60% risk of accreta

28
Q

what s/s do you see from placenta previa (4)

A
  1. painless pv bleeding
  2. relaxed uterus
  3. abnormal lie/ high presenting part
  4. present fetal heart sounds
29
Q

what are maternal complications of placenta previa (4)

A
  1. anemia
  2. PPH
  3. hypovolemic shock
  4. increased risk of maternal placenta acreta syndrome
30
Q

what are fetal complications of placenta previa (5)

A
  1. PPROM
  2. increase risk of premature birth
  3. IUGR
  4. intrauterine hypoxia
  5. malpresentation
31
Q

what investigations would you do in placenta previa (3)

A
  • FBC
  • vital signs
  • transabdominal USS
32
Q

what should you be prepared for in placenta previa if there is a previous uterine scar (2)

A
  • PPH
  • placenta accreta/ increta
33
Q

what clinical features can occur in placenta abruption (5)

A
  1. tender/ tense uterus ( woody hard)
  2. pv bleeding
  3. decreased/ absent fetal movements
  4. fetal distress
  5. possible shock
34
Q

what investigations do you do in placenta abruption (4)

A
  • FBC
  • grouping and cross match
  • vital signs
  • trans abdominal USS
35
Q

what is a common complication of placental abruption

A

couvelaire uterus ( uteroplacental apoplexy)

blood from the abruption infiltrates myometrium up to the serosa especially the cornua; giving myometrium bluish purple tone and making the uterus tense and rigid

36
Q

what are risk factors for placental abruption (10)

A

vascular changes:
1. HTN (vasoconstriction)
2. cocaine use (vasoconstriction)
3. smoking and alcohol
4. pre-eclampsia
stretching of the uterus:
5. polyhydraminos
6. multiple gestation

  1. sudden uterine decompression (ROM)
  2. prior placental abruption (4-12%)
  3. short umbilical cord
  4. trauma- car accident, fall, violence
37
Q

what is Sher’s classification of placental abruption (4)

A

grade 0
- asymptomatic patient with a small retroplacental clot

grade 1
- vaginal bleeding
- +/- uterine tetany and tenderness
- no signs of maternal shock
- no fetal distress

grade 2
- external vaginal bleeding possible
- no signs of maternal shock
- + signs of fetal address

grade 3
- external bleeding possible
- marked uterine tetany
- persistent abdominal pain
- + maternal shock
- + fetal demise (3a)
- coagulopathy present (3b)

38
Q

what are risk factors of uterine rupture (7)

A
  1. prior cesarean section (increases likelihood for rupture and placenta previa)
  2. uterine trauma ( c-section/ myomectomy from fibroids)
  3. uterine abnormalities e.g. uterine window (where myometrium is thinned out)
  4. hyperstimulation
    - medication induced like oxytocin
  5. recent pregnancy (uterus didn’t get enough healing time)
  6. overdistended uterus
    - macrosomia
    - polyhydraminos
    - multifetal
    - malpresentation (delay in labour progression)
  7. forceps assisted birth
39
Q

women with a hx of 2 previous scars have what risk for for developing uterine rupture

A

x5 greater risk than those with only one

40
Q

what are signs of imminent rupture (3)

A
  1. severe abdominal pain
  2. increase in contractions causing hyperactive labor
  3. bandl ring formation
41
Q

what are signs of uterine rupture (9)

A
  1. severe abdominal pain/ tender abdomen
  2. fetal distress
  3. sudden pause in contractions
  4. loss of fetal station
  5. easily palpable fetal parts
  6. hemodynamically instability- shock
  7. light to moderate vaginal bleeding
  8. subdiaphragmatic irritation causing pain to the shoulder
  9. +/- absent fetal movements and FHR
42
Q

what are risk factors for vasa previa (6)

A
  1. velamentous cord insertion
  2. Bilobed or Succenturiate Lobed Placenta
  3. In Vitro Fertilization (IVF):
  4. Multiple Pregnancies: Due to the potential for abnormal placental arrangements.
  5. Low-Lying Placenta
  6. Previous History of Vasa Previa
43
Q

what is type 1 vasa previa

A

The umbilical cord is inserted into the membranes instead of directly into the placenta. The fetal blood vessels then run within the amniotic membranes, directly over or close to the cervix.

44
Q

what is type 2 vasa previa

A

This type involves a placenta that has two or more lobes, with fetal blood vessels connecting these lobes. These vessels flow over or near the cervix, posing a risk during delivery

45
Q

what is type 3 vasa previa

A

In this less common form, one or more large vessels run through the membranes along the margin of the placenta and are located at the internal cervical opening. This type can often be seen in cases where a placenta previa has resolved

46
Q

what things can you get from history and exam for placenta abruption (5)

A
  1. Vaginal bleed
  2. tense/tender uterus
  3. decreased/absent fetal movements
  4. fetal distress/absent fetal heart sounds
  5. possible shock, from hypovolemia

Obs&Gynae (24 decks)

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