Bleeding In Late Pregnancy Flashcards
What is bleeding in late pregnancy called?
Antepartum haemorrhage
What is the definition of bleeding in early pregnancy?
before 24 weeks
What is the placenta?
Entirely fetal tissue Sole source of nutrition from 6 weeks Gas transfer Metabolism / waste disposal Hormone production (HPL & hGh-V) Protective filter Very vascular
What is the aetiology of an APH?
Placenta previa Placental abruption Local causes - Polyps, cancer, infection Uterine rupture Show
What are risk factors for placental abruption?
Pre-eclampsia/Hypertension
Trauma
Smoking/Cocaine/Amphetamine
Medical - Thrombophilias, Renal disease, diabetes
Poly-hydramnios, Multiple pregnancy, preterm-PROM
Abnormal placenta
What is Couvelaire uterus?
AKA uteroplacental apoplexy
Loosening of the placenta
What are clinical features of a placental abruption?
Small/Large blood loss Painful Uterine tenderness/Wooden hard Uterus feels bigger Difficulty to feel fetal parts CTG
What is Placenta Previa?
Placenta is partially or totally implanted in the lower uterine segment
What is the incidence of placenta previa?
5% at anomaly scan
1:200 at term
What are the classifications of placenta previa?
Lateral/Marginal/Incomplete/Centralis/Complete centralis
Grade I-IV
Major/Minor - distance from cervix by ultrasound
How is placenta previa diagnosed?
By Ultrasound
Painless ‘causeless’ recurrent 3rd trimester bleeding
Variable blood amount
Uterus is soft not tender
High head
CTG usually normal
Malpresentations - Breech/Transverse/Oblique
What should not be done until placenta previa is EXCLUDED?
Vaginal examination
When is the diagnosis of placenta previa made?
20 week scan then 32/34 week scan
What type of delivery is used in major degrees of placenta previa?
What type of delivery is used in minor degrees of placenta previa
> 2cm from OS = Consider vaginal delivery
What is Placenta Accreta?
When placenta invades myometrium
What has the placenta reached in Percreta?
The serosa
What is Placenta accreta associated with?
Severe bleeding
PPH and may end up having a hysterectomy
What are major risk factors for placenta accreta?
Placenta previa and prior caesarean delivery
Describe a Uterine Rupture?
Small/large blood volume Intra-partum-loss of contractions Previous CS/Uterine surgery Obstructed labour Peritonism Fetal head high Fetal distress/IUD Haematuria
What is Vasa Praevia?
Valementous insertion of cord/Succenturate lobe Fetal vessels within membranes Can be diagnosed ante-natally Fetal blood (200ml at term) Fetal death
What is the management of Placenta previa?
Admit IV access, blood tests/Cross match Scan Anti-D Steroids Delivery
How do you time delivery with placenta praevia?
May be preterm
CS at 37-38 weeks if been prior bleeding/ placenta accreta
CS at 38-39 weeks if not been bleeding in pregnancy
How do manage a Placental Abruption?
Admit IV access, bloods and cross match Resuscitate/Manage DIC Deliver viable baby-CS versus vaginal Stillbirth - vaginal delivery Anti-D Steroids if expectant management
What is the Antenatal admission criteria for any history of acute bleeding (23-32 weeks)
Min. stay of 24 hours clear of bleeding
What is the Antenatal admission criteria for recurrent bleeding after 28 weeks?
Min stay of 72 hours
Consider need to be admitted until delivery
What is the Antenatal admission criteria for any bleeding after 32 weeks?
Min stay of 72 hours
Consider need to be admitted until delivery
What is the Antenatal admission criteria for major placneta praevia after 36 weeks with no bleeding?
Consider the social circumstances
Consider other obstetric factors
Consider need for admission until delivery
Consultant decision
What antenatal benefit do steroids have?
Promote fetal lung surfactant production
Decrease respiratory distress syndrome by up to 50% if given 24-48 hours before delivery
Given up to 36 weeks
What dose of steroids are given ante-natally?
Betamethasone preferred to Dexamethasone
1 course = 12mg Betamethasone IM X2 injections, 12 hours apart
What other checks should be carried out?
Cervical - Colposcopy Infection - Swabs/Specific treatment PTL- Steroids +/- tocolysis Vasa praevia - CS Rupture - Laparotomy / CS Unknown - Conservative
Describe the delivery for suspected/Confirmed placenta accreta?
Ninewells delivery
CS at 37 weeks
Surgical plan clearly documented (including planned hysterectomy)
Cross match 6 units of blood
Cell salvage set up
Prior to surgery, consider inserting arterial line
What should be done regarding an antenatal admission with a pv bleed?
Secure wide bore venous access Check FBC Take blood group and save Cross match 2-4 units Check Kleihauer test + give anti-D
What should not be given in an antenatal admission with a pvbleed and what should be done?
NO - Enoxaparin thromboprophylaxis
YES - TEDS, Mobilisation, Hydration
What are antenatal risk factors for PPH?
Anaemia Previous CS Placenta praevia, placenta accreta Previous PPH or retained placenta Multiple pregnancy
What are intrapartum risk factors for PPH?
Prolonged labour
Operative vaginal delivery / CS
Retained placenta
What is the initial management for PPH?
Uterine massage
5 units IV Syntocinon stat
40 units Syntocinon in 500ml
Hartmanns - 125ml/h
What is the management for persistent PPH?
Confirm placenta and membranes complete Urinary catheter 500 micrograms Ergometrine IV (Avoid if cardiac disease/Hypertension Promptly repair and vaginal or perineal trauma
What are the non-surgical treatments of a PPH over 1500ml?
Packs & Balloons
Tissue sealants
Factor VIIa
Arterial embolisation
What is the surgical management of a PPH over 1500ml
Undersuturing Brace sutures Uterine artery ligation Internal iliac artery ligation hysterectomy
