Bleeding in late pregnancy Flashcards
What is the term of bleeding n late pregnancy
Antepartum haemorrhage
What is the definition of late pregnancy bleedin
After 24 weeks (in UK)
What are the main causes for bleeding in late pregnancy
Placenta previa Placental abruption Local -polps, infction, cancer Vasa previa -RARE Uterine rupture Show 40 percent no apparent cause
What is placental abruption
A separation of a normally implanted placental either partially or totally before birth of the fetus
What is the main risk factor for placental abruption
Pre-eclampsia/Hypertension
What other risk factors are there for placental abruption
Trauma Smoking and drugs Medical - thrombophilia, renal, diabetes Poly-hydramnios, multiple pregnancies Abnormal placenta
What is the recurrenc rate if abrutopn
10 percent
What are the clinical features of placental abruption
Small or large volume blood loss PAINFUL Uterine tenderness/wooden hard Uterus feels larger Difficult to feel fetal parts
What is the difference between revealed/concealed placental abruption
Revealed - blood come out of genital tract
Concealed- blood pools behind placenta
What is couvelair uterus
A lifethreatening complication of placental abruption whereby there is bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.
Name other complications of placental abruption
PPH
DIC
Death- maternal or fetus
What is placenta previa
Placental partially or totally implabted in the lower uterin segment
How common is placenta previa
5 percent of women at anomaly scan
1:200 at term
What are the classifications of placenta previa
Lateral - 1
Marginal- 2
Incomplete centralis - 3
Complete centralis -4
3 and 4 are over cervix
Major/minor - distance from cervix on ultrasound
What are the clinical features of placenta previa
Painless, ‘causeless’, recurrent 3rd trimesteric bleeding
Amount of blood variable
Uterus soft non tender
Malpresentations – Breech/Transverse/Oblique
High head
CTG usually normal
How is PP diagnosed
ULTRASOUND
Check anomaly scan!
20 week scan and 32/34 week scan should be done to decide type/extent of placent previa
What should no be performed in PP
vaginal examination
ALWAYS EXCLUDE PP beforehand
When would you consider a vaginal delievery in PP
If minor degree of PP ie more than 2cm from Os
When must a C section be done in PP
if placental less than 2cm from Os or covering Os
What is placenta accreta
Placenta invades myometrium
What is placenta percreta
Placenta has reached serosa
What is the risk factors for placenta accreta
Placenta previa
Prior C section
what is vasa previa
is an obstetric complication in which fetal blood vessels cross or run near the internal orifice of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue
When should you deliver in PP
Major bleeding may require preterm delivery
Caesarean Section at 37 - 38 weeks if there has been prior bleeding in pregnancy or suspected/confirmed placenta accreta
Caesarean Section at 38-39 weeks if there has not been bleeding in pregnancy
What type of delivery should be done in PA
C section
Vaginal if stillbirth
When should you admit a pregnant woman t hospital
Any history of acute bleeding 23 – 32 weeks
–Min stay of 24 hours clear of bleeding
Recurrent bleeding after 28 weeks
–Min stay of 72 hours
–Consider need to be admitted until delivery
Any bleeding after 32 weeks
–Min stay of 72 hours
–Consider need to be admitted until delivery
Major placenta praevia after 36 weeks with no bleeding
–Consider the social circumstances
–Consider other obstetric factors
–Consider need for admission until delivery
–Consultant decision
Why are steroids given
Promote fetal lung surfactant production
↓ neonatal respiratory distress syndrome (RDS) by up to 50% if administered 24-48h before delivery
When are steroids given in AP and PP
Administer up to 36 weeks. Only significant effects up to 34 weeks. Proven benefit up to 1 week
Which steroid is preferred
Betamethasone 12mg IM x 2 injections 12 hours apart
rather than dexmehtasone
When should you cross match a women with PV bleeding in pregnancy
cross match 2-4 units with a ny bleedin more than 1 tsp
what is kleihauer test
a blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother’s bloodstream.[1] It is usually performed on Rh-negative mothers to determine the required dose of Rho(D) immune globulin (RhIg) to inhibit formation of Rh antibodies in the mother and prevent Rh disease in future Rh-positive children.[2]
Should you give enoxaparin for DVT prophylaxis
NO - TEDS, mobilization and hydration only
What is the definition of PPH
loss of more than 500 ml of blood
Primary - in first 24 hrs
Secondary- more than 24hrs -6 weeks
What would a moderate or major PPH be
between 500ml - 1500ml
Major more than 1500ml
What are the four Ts of PPH
Tone - most common
Trauma
Tissue
Thrombin
What are the complications of PPH
Maternal fatigue, feeding difficulties, prolonged hospital stay, delayed lactation, pituitary infarction, transfusion, haemorrhagic shock, DIC, death
What are the risk factors for PPH antenatally
anaemia –previous caesarean section –placenta praevia, percreta, accreta –previous PPH or retained placenta –Multiple pregnancy
What are the intrapartum risk factors of PPH
–prolonged labour
–operative vaginal delivery / caesarean section
–retained placenta
What three intial things should be done to manage PPH
Uterine massage
5 units iv Syntocinon stat
40 units Syntocinon in 500ml
How sould persistant PPH be managed
Confirm placenta and membranes complete
Urinary Catheter
500 micrograms Ergometrine IV
(Avoid if Cardiac Disease / Hypertension)
? Vaginal / perineal trauma - ensure prompt repair
