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23- Obstetric Complications > APH Antepartum Haemorrhage > Flashcards

APH Antepartum Haemorrhage Flashcards

1
Q

What is the incidence of Placenta Previa at term? What are the risk factors for it ?

A

1 / 200
The incidence increased
1- in women with previous CS
2- maternal smoking
3- assisted reproductive technology
4- increased maternal age

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2
Q

What is the prevalence of placenta accreta?

A

1/ 300 - 1 / 2000

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3
Q

What is the chance of placental migration if diagnosed at 20 w ?

A

90% at 32w

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4
Q

What is the definition of :
- placenta praevia
- low lying placenta?

A

🚩placenta praevia: placenta lies directly over the internal os
🚩 low lying placenta: at > 16 w
placental edge is less than 20 mm from the internal os on TAS or TVS

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5
Q

At what gestation should we screen for placenta praevia, and when to follow up?

A

*At anomaly scan
*Follow up: TVS is recommended at
32 w to diagnose persistent low lying placenta
* further TVS at 36 w in women remain asymptomatic

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6
Q

What is the role & what are the risks of TVS in low lying placenta?

A

Is superior to TAS & is safe
Helpful for :
1-placenta localization Especially:for posterior placentas
2- To measure the cervical length

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7
Q

What is the role of measuring cervical length in the management decisions for women with placenta praevia?

A

A short cervical length( < 25 mm) on TVS before 34 w:
increases the risk of preterm emergency delivery & massive haemorrhage at CS

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8
Q

Where should women with low lying placenta be cared for in 3rd trimester, if she had recurrent bleeding?

A

Depends on women’s circumstances
( distance from the hospital, hb,..)
* if she was admitted to hospital: assess the risk factors for venous thromboembolism & balance the risk against the risk of bleeding
* if she was treated at home : should attend to the hospital immediately if : any bleeding or pain or contractions

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9
Q

Is there a place for cervical cerclage in women with low lying placenta?

A

IS NOT RECOMMENDED

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10
Q

At what gestation should women with placenta praevia be offered antenatal steroids?

A

SINGLE dose is recommended between 34 - 35 w
& delivery 1 w after
& prior to 34 in women with high risk of preterm delivery

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11
Q

Is there a place for tocolytics in women with symptomatic placenta praevia?

A

Maybe considered for 48h to administer antenatal steroids

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12
Q

At what gestation should planned delivery occur in women with low lying placenta?

A
  • Uncomplicated placenta praevia:
    36 - 37 w
  • history of vaginal bleeding or
    High risk of preterm delivery
    Late preterm delivery 34 - 36 w
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13
Q

What anaesthetic procedure is most appropriate for women having CS for placenta praevia?

A

Regional anesthesia
Is considered safe & associated with lower risk of haemorrhage than general anaesthesia

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14
Q

What blood products should be available in the delivery of women with placenta praevia?

A

1- rapid infusion & fluid warming devices should be available
2- cell salvage for women who decline blood products
⚠️ the decision to transfuse should be made on individual basis EVEN if preoperative hb < 70

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15
Q

What surgical approach should be used for women with placenta praevia?

A

1- consider vertical skin and / or uterine if the fetus is transverse lie particularly below 28w
2- consider preoperative & intraoperative US
3- if the placenta is transected during uterine incision 👉 immediately clamp the umbilical cord after fetal delivery
4- to control the haemorrhage:
- pharmacology
- intrauterine tamponade
- radiological techniques
- early hysterectomy

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16
Q

If placenta praevia is detected in 32 w , what is the percentage of it will resolve by term ?

A

50 %

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17
Q

How many of placentas diagnosed as low lying at routine anomaly scan TVS will reclassify them?

A

26 - 60 % of them

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18
Q

Compare CS for placenta praevia with CS for other indications, regarding risk of massive haemorrhage/ the need for blood transfusion?

A

The risk of massive haemorrhage is approximately 12 times more likely in CS for placenta praevia

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19
Q

What is the success rate in controlling PPH for Intrauterine balloon tamponade in women with placenta praevia ?

A

75 - 88%

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20
Q

What are the surgical procedures should be used for women with placenta praevia to reduce blood loss & the risk of PPH?

A

1- J shaped uterine incision for anterior placentas instead of cutting through the placenta
2- intrauterine balloon tamponade
( Bakri balloon, BT cath ) 400ml / warm saline
3- endouterine sutures ( B-lynch)
4- radiological techniques: transarterial embolization of internal iliac artery

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21
Q

What is the incidence of placenta praevia after CS?

A

4,5 for one CS
7,4 for 2 CS
6,5 for 3 CS
44,9 for 4 CS or more
according to 2014 studies:
10 / 1000 with 1 CS
28 / 1000 with 3 CS or more

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22
Q

What is the prevalence of malpositions of the fetus occurring with placenta praevia?

A

35 % of cases the fetus is malpositioned ( transverse/ breech)

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23
Q

What is the definition of placenta accreta ?

A

A spectrum disorder ranging from abnormally adherent to deeply invasive tissue

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24
Q

If the woman with placenta praevia is asymptomatic & wish for vaginal birth, how to make a decision?

A

By TVS
If the placental edge less than 20 mm from the internal os in the 3rd trimester OR
placental edge is thicker than 10 mm
👉 CS

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25
Q

Women with placenta praevia having CS are at increased risk of blood loss, what are the risk factors for massive haemorrhage?

A

1- placenta covering the internal os
2- anterior placentation
3- pre delivery anaemia
4- thrombocytopenia
5- diabetes
6- magnesium use

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26
Q

Case : woman with placenta praevia + transverse fetal position < 28w
How to perform CS?

A

Vertical skin / uterine incision
Classical CS

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27
Q

What are the factors associated with the failure of Bakri balloon tamponade for placenta praevia?

A

1- previous CS
2- anterior placentation
3- thrombocytopenia at the time of insertion
4- coagulopathy at the time of insertion
5- PPH volume > 500 ml within the first hour of placement

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28
Q

Management Summary placenta praevia at 3rd trimester:
Asymptomatic / symptomatic?
Asymptomatic low lying placenta?

A

Asymptomatic 👉 steroids 34 - 36 w
Schedule CS 36 - 37 w
Symptomatic👉 steroids before 34w
Schedule CS 34 - 36 w
Asymptomatic low lying placenta 👉
Repeat scan at 36w if still 👉
Individualized decision offered

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29
Q

What are the risk factors for placenta accreta spectrum?

A

1- history of accreta in previous pregnancy
2- previous CS
3- uterine surgery
4- repeated endometrial curettage
5- placenta praevia
6- increased maternal age > 35
7- ART
8- uterine pathology: adenomyosis, submucous fibroids ،bicornuate uterus
9- cesarean scar pregnancy
10- postpartum endometriosis

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30
Q

What are the factors that should alert the antenatal team of the higher risk of placenta accreta?

A

Previous CS + Anterior low lying placenta /or placenta praevia

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31
Q

After one prior CS , how many times the risk of invasive placentation increases?

A

7 folds

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32
Q

What is the median estimated blood loss of placenta accreta? And the median number of blood transfused?

A

2000 - 7800 ml
5 blood units

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33
Q

How many of placenta accreta remains undiagnosed before delivery?

A

1/2 - 2/3 in population studies

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34
Q

What is the role of US imaging in diagnosing placenta accreta?

A

Highly accurate
With high sensitivity & specificity

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35
Q

Among US signs of placenta accreta
Which has the best predictive accuracy ?
Which has best specificity?

A

🚩Predictive accuracy:Abnormal vasculature on color doppler
🚩Specificity: Abnormality of the uterus bladder interface

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36
Q

What is the risk of placenta accreta in women presenting with placenta praevia and :
1-No previous CS
2-prior CS after : 1 /2 /3 /4 /5 CS?

A

No prior CS 3-4%
1 CS 3%
2 CS 11%
3 CS 40 %
4 CS 61 %
5 CS or more 67%

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37
Q

What is the definition of:
Accreta / increta / percreta ?

A

*Accreta: villus attach directly to the myometrium in the absence of decidua
* increta : villus invade deeper in the myometrium, don’t extend to serosa
* percreta : the villus reach the serosa

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38
Q

What are the most common US signs associated placenta accreta spectrum?

A

1-Placental lacunae give the placenta a MOTH EATEN appearance on grayscale imaging
2- increased vascularity of placental bed with large feeder vessels entering the lacunae

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39
Q

What is the role of MRI in diagnosing placenta accreta?

A

⚠️Diagnostic value of MRI & US in detecting placenta accreta is similar
* help to assess the invasion of myometrium especially with: -posterior placentation
-US suggestive parametrial invasion

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40
Q

What is the role of MRI with IV gadolinium injection in diagnosing placenta accreta?

A

Increase the sensitivity of MRI
But safety is limited

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41
Q

When should delivery be planned for women with placenta accreta?

A

MDT
35 - 37 w

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42
Q

What is the likelihood of emergency delivery in cases of placenta accreta after 34w of pregnancy?

A

20%

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43
Q

What is massive blood transfusion?

A

8 units or more

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44
Q

What are the risks associated with the delivery of placenta accreta?

A

1- massive haemorrhage 👉coagulopathy
2- multisystem organ failure
3- death

45
Q

What are the 6 elements considered to be reflective of good care in delivering placenta accreta?

A

1- consultant obstetrician
2- consultant anaesthetist
3- blood products available
4- MDT
5- discuss possible interventions:
Hysterectomy, leaving the placenta in situ ..)
6- local availability of level 2 critical care bed

46
Q

What surgical approach should be used for women with placenta accreta spectrum?

A

1-planned preterm CS hysterectomy with placenta left in situ is preferable
2- uterus preserving surgery: partial myometrial resection, in case of the extend of placenta accreta is limited

47
Q

What is the role of ureteric stents in the surgery for placenta accreta?

A

Insufficient data to recommend the routine use
* may have a role when the bladder is invaded by placental tissue

48
Q

In cases of placenta accreta what is the risk of hysterectomy during attempting placental remove?

A

100 % of the cases

49
Q

What is triple P procedure as a surgical approach for placenta accreta?

A

*perioperative placental localization
* pelvic devascularization
*placental non separation
Transverse uterine incision + myometrial excision & reconstruction of the uterine wall

50
Q

What surgical approach should be used for women with placenta percreta?

A

1- primary hysterectomy following delivery
2- delivery of the fetus + repair the incision + leave the placenta in situ
3- delivery of the fetus without disturbing the placenta then partial excision of the uterus wall
4- delivery of the fetus without disturbing the placenta & leave the placenta then elective hysterectomy 3-7 days later

51
Q

What is the role of ureteric stents in the surgery for placenta percreta ?

A

It is recommended to pre operative cystoscopy and placement of ureteric stents

52
Q

In a case of placenta percreta if the bladder is involved what surgical approach should be considered?

A

Planned cystotomy

53
Q

What are the risks of expectant management of placenta accreta ( leaving the placenta in situ?

A

Bleeding & infection

54
Q

What is the role of MTX adjutant therapy in the expectant management of placenta accreta( leaving the placenta in situ)?

A

Should not be used
Unproven benefit and has significant side effects

55
Q

If at the time of elective CS find out presence of placenta accreta and the mother & baby are stable, what is the management?

A

CS should be delayed until appropriate staff and adequate blood products are available

56
Q

In case of unsuspected placenta accreta spectrum diagnosed after the birth of the baby , what is the best approach?

A

Placenta should be left in situ and perform emergency hysterectomy

57
Q

What is the prevalence of vasa praevia?

A

1/ 1200 - 1/ 5000

58
Q

How is vasa praevia usually diagnosed?

A

1- during early labour detecting pulsating fetal vessels by vaginal examination
2- presence of dark red bleeding & acute fetal compromise after spontaneous or artificial rupture of membranes

59
Q

How is vasa praevia classified?

A

Type 1( 90 %) : when the vessel is connected to a velamentous umbilical cord
Type 2 (10%) : when the vessel connects the placenta with succenturiate or accessory lobe

60
Q

What is the fetal mortality associated with vasa praevia?

A

60 %

61
Q

What is the average fetal blood loss in case of vasa praevia bleeding in labour?

A

80 - 100 ml / kg

62
Q

If stillbirth has occurred in a case of vasa praevia, how to confirm the diagnosis?

A

Placental pathological examination

63
Q

What is the association between vasa praevia & placenta praevia?

A

60 % of women with vasa praevia at delivery have placenta praevia or low lying placenta identified during the 2nd trimester

64
Q

If vasa praevia is diagnosed in the 2nd trimester, what is the percentage that will be resolved before delivery?

A

20 % of cases

65
Q

At what gestation should elective delivery occur in a case of diagnosed vasa praevia?

A

Planned CS at 34 - 36 in asymptomatic women

66
Q

Case : woman in labour+ abnormal CTG ( HR 90) after rupture of membranes, what to suspct, what is the management?

A

Vasa praevia
Category 1 CS ( emergency)

67
Q

What is the painless vaginal bleeding caused by vasa praevia called?

A

Benckeiser’s haemorrhage

68
Q

Can vasa praevia be diagnosed during fetal anomaly scan?

A

High diagnostic accuracy
With low false positive rate

69
Q

What is the investigation that has the best diagnostic accuracy for vasa praevia?

A

Combination of both trans abdominal & transvaginal color doppler imaging CDI

70
Q

What is the definition of vasa praevia?

A

Vessel running in the free placental membranes within 2 cm of the cervix

71
Q

What are the risk factors for vasa praevia that indicate midpregnancy US assessment to screen for vasa praevia?

A

1- placenta praevia
2- bilobed placenta
3- succenturiate lobes
4- ART
5- velamentous cord insertion

72
Q

How should women with vasa praevia be managed?

A

1- prophylactic hospitalization
30 - 32 w
2- antenatal steroids 32 w
3- planned CS 34-36 w

73
Q

What is the percentage of pregnancies complicated by APH ?

A

3- 5 % of pregnancies

74
Q

What is the proportion of preterm deliveries caused by APH ?

A

1 / 5 of the preterm babies

75
Q

What is the recurrence rate of placental abruption after 1 abruption & 2 abruptions?

A

After 1 abruption 👉 4.4 %
After 2 abruptions 👉 19 - 25 %

76
Q

What is the proportion of abruption cases the USG fails to detect?

A

3 / 4

77
Q

What is the percentage of placental abruption abnormal CTG detected with?

A

69 %

78
Q

What is the prevalence of placental abruption?

A

3-6 / 1000 of pregnancies

79
Q

What is the perinatal mortality rate for placental abruption?

A

Up to 48 %

80
Q

What is the lower limit of gestational age to define placental abruption?

A

As low as 20 weeks

81
Q

How many of placental abruption cases found to be in low risk pregnancies?

A

70 % of the cases of placental abruption in low risk pregnancies

82
Q

What are the clinical features of placental abruption?

A

1- vaginal bleeding 70 -80 %
2- abdominal pain 50 %
3- uterine tenderness 70 %
4- fetal distress 65 %
5- fetal death 15 %
6- DIC
7- maternal shock

83
Q

What is the definition of APH ?

A

Bleeding from genital tract occurring from 24 w of pregnancy and before the birth of the baby

84
Q

What is the definition of : minor / major/ massive haemorrhage regarding APH ?

A

*Minor: < 50 ml % settled
*Major: 50 - 1000 ml with no signs of clinical shock
*Massive: > 1000 ml &/or signs of clinical shock

85
Q

What are the risk factors for placental abruption?

A

1- PET 2- FGR
3- non vertex presentation
4- advanced maternal age
5- low BMI
6- pregnancy following ART
7- PROM 8- smoking
9- abdominal trauma
10 - intrauterine infection
11- drug misuse ( cocaine/ amphetamines)
12 - multiparty
13 - polyhydramnios
⚠️ first trimester bleeding increases the risk of placental abruption

86
Q

What is the association between thrombophilia & placental abruption?

A

Significant associated with:
-Heterozygous factor v leiden
-Heterozygous prothrombin gene mutation

87
Q

Can APH be predicted?

A

APH has heterozygous pathophysiology & CANNOT be predicted

88
Q

Can APH be prevented?

A

Change modifiable risk factors
Smoking/ drug misuse
⚠️ folic acid supplements has no conclusive evidence of benefit
⚠️ no good data to support the use of aspirin/ LMWH in women with thrombophilia to prevent placental abruption

89
Q

What are the maternal complications of APH?

A

Anaemia / infection / shock
Postpartum hemorrhage
Renal tubular necrosis

90
Q

What are the fetal complications of APH?

A

Hypoxia / SGA / prematurity/ death

91
Q

What is the incidence of cervical cancer in delivery ?

A

7.5 / 100,000 delivery
Half of them had previous abnormal cervical smear

92
Q

How to make an assessment for women with APH ?

A

1- collapse 👉 ABC
2- pulse + BP
3- abdominal palpitation
4- speculum examination
5- digital vaginal examination

93
Q

What maternal investigations should be performed in women presenting with APH?

A

⚠️ kleinhauer test for rhesus D negative women
2- US to diagnose placenta praevia
3- placental abruption is a clinical diagnosis
4- blood tests:
* minor: full blood count & group
* massive: CBC,coagulation screen, 4 units cross matched, urea ,electrolytes, LFTs

94
Q

What fetal investigations should be performed in women presenting with APH ?

A

CTG ( abnormal CTG in 69 % of placental abruption cases)
US if viability cannot be detected using auscultation

95
Q

Should women with APH be hospitalized ?

A

*Spotting + no longer bleeding + placenta praevia excluded 👉home
* heavier than spotting or ongoing bleeding 👉 hospitalize until the bleeding has stopped
* history of IUFD resulting from placental abruption 👉 hospitalization

96
Q

Should steroids be administered to women who present with APH before term?

A

24 - 34 w 👉 offer single dose of steroids
Even if spotting & imminent delivery is unlikely

97
Q

Should tocolytic therapy be used in women presenting with APH who have uterine activity?

A

Contraindicated in placenta praevia
Contraindicated in placental abruption
ONLY in those needing transverse to other hospital

98
Q

If tocolytic drugs is indicated in a woman with APH , what are the considerations about them?

A

Calcium antagonist(nifedipine ) best avoided ( maternal hypertension)

99
Q

Should the antenatal care of a woman be altered following APH?

A

1- pregnancy should be classified as High risk pregnancy
2- antenatal care should be consultant led
3- serial US for fetal growth

100
Q

If the woman has unexplained APH ,she is at increased risk of pregnancy complications, which has the highest risk?

A

🏅 oligohydramnios
- IUGR
- PROM
- Preterm labour
- CS

101
Q

When should women with APH be ddelivered?

A

🚩< 37w & no fetal or maternal compromise & bleeding has settled
👉 conservative management
🚩 > 37w or major APH 👉 induction of labour

102
Q

What intrapartum fetal monitoring should be employed for women whose pregnancies were complicated by APH ?

A

📢 Continuous CTG:
1- active vaginal bleeding
2- preterm delivery with major APH or recurrent minor APH
3- clinical suspicion of an abruption
4- minor APH with placental insufficiency ( IUGR / oligohydramnios)
📢 Minor episodes with no other concerns 👉 intermittent auscultation

103
Q

What is the appropriate management of the 3rd stage of labour in women with APH ?

A

*Placental abruption or placenta praevia 👉 STRONGLY RECOMMEND
Active management 3rd stage
*Consideration of ergomethrin- oxytocin

104
Q

Should women presenting with APH who are RhD negative be given anti - D Ig?

A

⚠️ Anti- D should be given after any presentation with APH independent of routine prophylactic anti-D
⛔ recurrent APH after 20w 👉 anti-D at least 500 iu every 6 weeks
Then test FMH
If FMH > 4 ml 👉 additional anti -D

105
Q

How should women presenting with APH who develop coagulopathy be managed?

A

Clotting studies
+ 4 units FFP + 10 units cryoprecipitate whilst waiting the results ( 2 packs)

106
Q

What is the initial management for women with APH [ ABCD]?

A

*A airway
*B breathing ( 10 - 15 l / min ) via facemask
*C circulation ( 14 gauge IV access) + 20 ml blood for tests
*D assess the fetus & mode of delivery

107
Q

What is the full protocol for massive haemorrhage of APH > 1000 ml or clinical shock?

A

Airway, breathing, circulation
Facemask 10 - 15 l/ min
2 IV access
Left lateral position tilt
Keep the woman warm
3.5 L crystalloid
Transfuse blood as soon as possible
ℹ special blood filters SHOULD NOT be used ( slow infusions)

108
Q

About blood products transfusion:
When to give: FFP,PLT,cryoprecipitate?

A

FFP :4 units for every 6 units of RBCs
If Pt or Ptt > 1.5 mean control
Plt : if plt count < 50
Cryoprecipitate: if fibrinogen < 1 g/L

109
Q

What is the main therapeutic goal of the management of massive blood loss?

A

1- Hb > 8
2- plt > 75
3- Pt < 1.5
4- Ptt < 1.5
5- fibrinogen > 1 g/ L

23- Obstetric Complications (6 decks)

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