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reproduction & sexual health > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

Define antepartum haemorrhage

A

Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour

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2
Q

What are the key functions of the placenta?

A
  • gas transfer
  • metabolism/waste disposal
  • hormone production (HPL, hGhV)
  • protective filter
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3
Q

What can cause antepartum haemorrhage?

A 
Placental problem - praeiva/abruption 
Uterine problem - rupture 
Local causes - ectropion, polyps, infection, carcinoma 
Vasa praevia
Indeterminate
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4
Q

State the differential diagnosis of antepartum haemorrhage

A

Heavy show, cystitis, haemorrhoids

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5
Q

Describe the classifications of antepartum haemorrhage

A

Spotting - staining, streaking, wiping
Minor - <50ml settled
Major - 50-100ml no shock
Massive - >1000ml +/- shock

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6
Q

Define placental abruption

A

Separation of a normally implanted placenta can occur partially or totally before birth of the foetus

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7
Q

Describe the pathology behind placental abruption

A

Vasospasm followed by arteriole rupture into the decidua, blood escapes into the amniotic sac or further under the placenta and into the myometrium
Tonic contraction and interrupts placental circulation causing hypoxia

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8
Q

What is meant by couvelaire uterus?

A

Haematoma bruised uterus, that does not contract

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9
Q

State the risk factors for placental abruption

A 
70% unknown, low risk pregnancies 
Pre-eclampsia 
Trauma 
Smoking/drugs
Medical conditions - renal, thyroid, diabetes, coagulopathy
Polyhydramios 
Abnormal placenta 
PROM 
Previous abruption
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10
Q

What are the symptoms of placental abruption?

A

Severe continuous abdominal pain, backache if posterior placenta, bleeding, pre-term labour

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11
Q

What are the signs of placental abruption?

A

Very unwell patient, uterus may be large, tender and woody hard

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12
Q

What is meant by woody hard uterus?

A

Unable to identify fetal parts

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13
Q

Describe the fetal signs of placental abruption

A

Fetal distress - bradycardia/absent heart beat/tachycardia

CTG - irritable uterus, loss of variability, decelerations, tachycardia

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14
Q

What does a CTG of an irritable uterus show?

A

1 contraction/minute

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15
Q

How do you resusciate a mother?

A

2 large bore IV access, bloods - FBC, clotting, LFT, U and E, crossmatch 4-6 units, Kleihaur
IV fluids, catheterise and urometer

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16
Q

How is placental abruption managed?

A

Minor - expectant, allow steroid cover
Mild - induce labour by amniotomy
Major - C-section

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17
Q

What are the maternal complications of placental abruption?

A 
Hypovolaemic shock 
Anaemia
PPH 
Renal failure due to tubular necrosis 
DIC, coagulopathy 
Infection 
Complications of blood transfusion 
Thromboembolism
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18
Q

What are the fetal complications of placental abruption?

A 
IUD 
Hypoxia
Preterm (iatrogenic/spontaneous)
Small baby 
Fetal growth restriction
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19
Q

How can placental abruption be prevented?

A 
Anti-phospholipid Syndrome management 
Drug misuse 
Smoker 
Folic Acid 
Screen for domestic violence
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20
Q

Define placenta praevia

A

Placenta lies directly over the internal os

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21
Q

Define low lying placenta

A

After 16/40 when the placental edge is less than 20mm from the internal os on ultrasound

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22
Q

What is special about the lower uterus?

A

Below the utero-vesical peritoneal pouch superiorly and the internal os inferiorly it contains less muscle fibres and does not contract instead passively dilates
7cm from the internal os

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23
Q

State the risk factors for placental praevia

A 
Previous c-section 
Previous TOP 
Advanced maternal age >40 
Multiparity/multiple pregnancy 
Assisted conception 
Smoking
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24
Q

What can make a uterus deficient?

A

Presence of uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid

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25
Q

How is placenta praevia screening for and diagnosed?

A

Midtrimester fetal anomaly scan includes placenta localisation - rescan at 32 and 36 weeks if persistent
Transvaginal scan
Assess cervical length <34 weeks if risk of preterm labour

26
Q

State the symptoms of placenta praevia

A

Painless bleeding >24 weeks, may be triggered by coitus, can be minor and fetal movements usually present

27
Q

What are the signs of placental praevia?

A

Uterus soft non tending with high presenting part commonly malpresenations with normal CTG

28
Q

What must not be done in placenta praevia?

A

Digital examination

29
Q

How is placenta praevia managed?

A 
ABCDE 
Assess baby 
Resus - admit for at least 24 hours 
TED stockings 
No sex 
Delivery plan and magnesium sulphate
30
Q

If a woman has placenta praevia and is bleeding describe the management

A 
Resus 
Major haemorrhage protocol 
IV fluids and transfuse 
Anti-D
Monitor fetal heart on CTG 
Steroids 24-36weeks 
Magnesium sulphate 
Deliver if active bleeding
31
Q

Describe delivery options in placenta praevia

A

C-section; if placenta covers os or <2cm from cervical os Vaginal if placenta >2cm from os and no malpresentation

32
Q

What do you need to consent for in C section?

A

General anaesthetic
Hysterectomy
Cell salvage
Vertical incision

33
Q

Define placenta accreta

A

Morbidly adherent placenta - abnormally adherent to the uterine wall

34
Q

What are the risk factors for placenta accreta?

A

Previous c section, placenta praevia

35
Q

Name the two grades of placenta accreta

A

Invading myometrium - increta

Penetrating uterus to bladder - percreta

36
Q

How is placenta accreta managed?

A

Prophylactic internal iliac artery balloon
Caesarean hysterectomy
Blood loss >3l expected
Conservative management and methotrexate - deliver baby and abode placenta by cutting upper segment of uterus

37
Q

What is meant by uterine rupture?

A

Full thickness opening of uterus including the serosa

38
Q

What is a rupture called when the serosa is intact?

A

Dehinscence

39
Q

State the risk factors for uterine rupture

A

Previous c-section/uterine surgery, multiparity, use of prostaglandins/syntocinon, obstructed labour

40
Q

What are the symptoms of uterine rupture?

A

Severe abdominal pain, shoulder tip pain, maternal collapse, PV bleeding

41
Q

What are the signs of uterine rupture?

A 
Intra-partum loss of contractions
Acute abdomen 
Presenting part rises 
Peritonism 
Fetal distress/IUD
42
Q

How is uterine rupture managed?

A

Resus and surgery

43
Q

Define vasa praevia

A

Unprotected fetal vessels transversing the membrane below the presenting part over the internal os - will rupture during labour/amniotomy

44
Q

How is vasa praevia diagnosed?

A

Ultrasound TA or TV with doppler

Clinically - sudden dark red bleeding and fetal distress

45
Q

Name the two types of vasa praevia

A

type 1 - vessel is connected to a velamentous umbilical cord
type 2 - vessel connects the placenta with succenturiate/accessory lobe

46
Q

What are the risk factors for vasa praevia?

A

Placental anomalies
History of low lying placenta in second trimester
Multiple pregnancy
IVF

47
Q

How is vasa praevia managed?

A

Steroids
Elective C-section 34-36 weeks if detected
APH - emergency c-section

48
Q

Define post partum haemorrhage

A

Blood loss >500ml after the birth of the baby

49
Q

What are the two types of PPH?

A

Primary - within 24 hours of birth

Secondary - >24 hours to 6 weeks post delivery

50
Q

What are the two classifications of PPH?

A

Minor - 500ml-1000ml without shock

Major - >1000ml or signs of CV collapse/on-going bleeding

51
Q

State the four Ts of PPH

A

Tone
Trauma
Tissue
Thrombin

52
Q

What are the antenatal risk of PPH?

A

Anaemia, C-section, placenta problems, previous PPH, multiple pregnancy, obesity, polyhydramios, fetal macrosomia

53
Q

What are the intrapartum risk of PPH?

A

Prolonged labour, operative delivery, C-section, retained placenta

54
Q

What is given in stage 3 to prevent PPH?

A

Syntocinon and syntometrine IM/IV

55
Q

State the three key steps in managing PPH

A
  • Assess
  • Stop Bleeding
  • Fluid Replacement
56
Q

Describe the assess part of PPH management

A

Vital signs - pulse, BP, cap refill, stats every 15 mins
Oxygen high flow 6l/min
Determine cause
Blood samples - FBC, clotting, fibrinogen, U/E, LFT, lactate, cross match 6 units

57
Q

How is fluid replacement in PPH carried out?

A

2 large bore IV access - rapid fluid resuscitation with crystalloid, hartmann’s or 0.9% saline
Blood transfusion and warming
DIC/coagulopathy
Cell saver

58
Q

What is tried first to stop the PPH bleeding?

A 
Uterine massage/bimanual compression 
Expel clots 
IV stat - 5 units syntocinon 
Infusion 40 units syntocinon in 500ml Hartmann's 
Foleys Catheter with hourly volumes
59
Q

If step one fails what is done next?

A 
Ergometrine 
Carboprost/haemabate 
Misoprostol 
Tranexamic Acid 
Examination under anaesthetic
60
Q

Name three non-surgical techniques to stop PPH

A

Packs and balloons (Bakri or Rusch)
Tissue sealants
Interventional radiology (arterial embolisation)

61
Q

Name the surgical techniques to stop PPH

A

Understuturing, brace sutures, uterine artery ligation, internal iliac artery ligation, hysterectomy

62
Q

What is required post delivery and PPH?

A

Thromboprophylaxis, debrief couple, manage anaemia

reproduction & sexual health (36 decks)

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