Antepartum hemorrhage Flashcards
Define antepartum hemorrhage
Vaginal bleeding after 24wks gestation to birth
Hemodynamic changes during pregnancy
Cardiac Output increases from 4.5ml/min - 6ml/min during the first 10 wks of pregnancy
Plasma/blood volume increases by 45-50%
RBC increase by 33% - plasma vol increases faster in 1st trimester so hematocrit initially falls aka Hemodilution
The white blood cell count increases and may peak at over 20 mg/mL
Platelet production, activation and consumption increases but generally decreases
Increase in fibrinogen VII,VIII, IX, X and XII
Differential diagnosis
Placenta praevia most common Placental abruption Vasa previa Bloody show Cervical lesion (cervicitis, polyp, cervical erosion, cervical Ca) Uterine rupture
Definition of placenta praevia
Implantation of the placenta in the Lower uterine segment.
Lower uterine segments is formed from isthmus, 5cm from internal os and is part that dilates not contracts during labour
Types of placenta praevia
Marginal - placenta less that 2cm from internal os
Partial - placenta covers internal os but not completely
Complete - placenta completely covers the internal os
What causes placenta previa
Suspected endometrial damage from prior full term pregnancies.
NB 90% diagnosed early would resolve on its own due to the placenta growing towards the vascularized fundus
Presentation of placenta previa
PAINLESS, bright red vaginal bleeding, which occurs spontaneously or after coitus and around 30 wks gestation
“warning hemorrhages” small painless bleeds that occur a few weeks prior to a heavy bleed
NB Blood loss is of maternal origin
What would you find on examination for placenta previa
Vitals: person would be hypotensive and tachycardic aka decrease in BP and increase in HR
Abdominal exam: abdomen soft and nontender, presenting fetal part may be high or frank malpresentation
What investigations would you do for placenta previa
Vaginal exam is CONTRAINDICATED in placenta previa
Transvaginal U/S is more accurate than a transabdominal U/S
If placenta is <2cm from internal os after wk20, repeated in the 3rd trimester to see if location has changed
How would you manage a patient with placenta previa <37wks with minial bleeding
Goal is to prolong pregnancy until 37 weeks
ADMIT for rest of pregnancy
Full detailed obstetric Hx and examination
Investigations: Set up an IV line with a large-bore brannula, CBC, U&E, GXM, PT/PTT and set up N/S drips
If RH –ve, give RhoGAM
Order 2 units packed RBCs
Resuscitate (if necessary) and Monitor vital signs
Consider corticosteroids to mature fetal lungs
How would you manage a patient with placenta prvia <37wks with profuse bleeding
State that is an OBSTETRIC EMERGENCY
* Stabilize the patient - ABCDEs with C being very important. Site 2 large bore branula and investigate CBC, U&E, GXM, PT/PTT
Request 2 units of PRBC (for blood loss)and FFP (could have DIC)
* Resuscitate - starting with crystalloids like N/S
Fetal testing with CTG
C-section
How would you manage a patient with placenta previa >37wks with profuse bleeding
State that is an OBSTETRIC EMERGENCY
* Stabilize the patient - ABCDEs with C being very important. Site 2 large bore branula and investigate CBC, U&E, GXM, PT/PTT
Request 2 units of PRBC (for blood loss)and FFP (could have DIC)
* Resuscitate - starting with crystalloids like N/S
Fetal testing with CTG
C-section
Definition of placental abruption
Defined as the separation of the placenta prior to delivery of the fetus
Cause of placental abruption
Cause is unknown but risk factors include:
Maternal hypertension 44%
Trauma 1.5 - 9.4%
Cigarette smoking/tobaco use
Cocaine abuse (13-35% of ppl who abuse coaine)
Previous placental abruption
Pathophysiology of placental abruption
In most cases it is initiated by rupture of uterine vessels, (mainly uterine arteries) leading to bleeding into the decidua basalis causes it to be separated from the myometrium
It this is at the center of the placenta. vaginal bleeding may not occur (Concealed)
If it initiates at edge of placenta, or spreads to the edge, vaginal bleeding may occur (revealed)
