Bleeding in late pregnancy

Question 1

when is bleeding in early pregnancy

Answer 1

<24 weeks

Question 2

when is bleeding in late pregnancy (antepartum haemorrhage) in the uk

Answer 2

> and equal to 24 hours

Question 3

functions of the placenta

Answer 3

sole source of nutrition form 6 weeks 
gas transfer 
mtabolism/waste disposal
hormone production 
protective filter

Question 4

definition of antepartum haemorrhage

Answer 4

bleeding form the genital tract after 24 weeks of gestation

Question 5

causes of APH

Answer 5

placenta previa 20%
placental abruption 30%
local causes such as polyps, cancer, infection 
vasa previa
uterine rupture

Question 6

what is the most comments cause of APH

Answer 6

idiopathic

Question 7

what is placental abruption

Answer 7

separation of a normally implanted placenta partially or totally before the birth of the fetus

Question 8

risk factors for placental abruption

Answer 8

PET/hypertension 
trauma
smoking/cocaine/amphetamins
medical such as thromboembolic/renal/DM
polyhydraminios, multiple pregnancy, preterm PROM
abnormal placenta 
recurrence rate 10%

Question 9

what are the two types of placental abruption

Answer 9

concealed

revealed

Question 10

what are the clinical features of placental abruption

Answer 10

pain
uterine tenderness/wooden hard
uterus feels larger
difficult to feel fetal parts

sudden onset abdominal pain, vaginal bleeding and uterine tenderness
abnormally frequent contractions and uterine hypertonus

Question 11

ix for placental abruption

Answer 11

CTG

Question 12

what is placental previa

Answer 12

placenta is partially or totally implanted in the lower uterine segment

Question 13

incidence of placenta previa

Answer 13

5% at anomaly scan

1:200 at term

Question 14

classifications of placenta previa old and new

Answer 14

old - lateral/marginal/incomplete centralis and complete centralis

major - over the uterus completely or slightly over the uterus
minor - not over the uterus

Question 15

clinical signs and symptoms of placenta previa

CTG readings

Answer 15

painless recurrent third trimester bleeding
amount of blood variable
uterus soft and non tender
malpositions - breech, transverse, oblique
high head
CTG usually normal

Question 16

dx of placenta previa

Answer 16

US - scan for this at 20 weeks then a scan at 32/34 weeks

Question 17

what should not be done until placenta previa has been excluded

Answer 17

vaginal exam

Question 18

types of delivery with placenta previa

Answer 18

major <2cm from os/covering os -> CS

minor >2cm from os -> vaginal delivery

Question 19

what is placenta accreta

Answer 19

placenta invades myometrium

Question 20

what are the major risk factors for placenta accreta

Answer 20

placenta previa and prior cs

Question 21

what can happen during uterine rupture

what is the common cause

Answer 21

small or a large volume 
intra partum - loss of contractions
obstructed labour 
fetal head high 
fetal distress

previous CS/uterine surgery

Question 22

what is vasa praevia

Answer 22

some of the babies vessels are run across and are unsupported by the placenta so are at risk of rupture

Question 23

dx of vasa praaevia

Answer 23

can be dx antenatally

Question 24

local causes of APH signs

Answer 24

small volume
painless
provoking factor
uterus soft and non tender
no fetal distress
normally sited placenta

Question 25

management of APH

Answer 25

ABCDE for mums safety

fetal safety

Question 26

management for placenta previa

Answer 26

admit
IV access, blood tests/cross match
scan
anti D
steroids 
delivery

Question 27

delivery in placenta preview

Answer 27

CS at 37-38 weeks if there is prior bleeding in preg or suspected/confirmed placenta accreta
CS at 38-19 weeks if there has not been bleeding in preg
major bleeding may require preterm delivery

Question 28

antenatal admission criteria and the minimum stay for east

Answer 28

acute bleeding at 23-32 weeks - min stay of 24 hours clear of bleeding

recurrent bleeding after 28 weeks - min stay of 72 hours, consider admitting till delivery

any bleeding after 32 hours - min stay of 72 hours, consider admitting until delivery

major placenta praaevia after 36 weeks with no bleeding - consider shit

Question 29

steroids are given why

how

Answer 29

promotore fetal lung surfactant production
decrease NRDS by 50% if given within 24-48 hours before delivery
administer up to 36 weeks
betamethasone
12mg IM twice 12 hours apart

Question 30

cervical causes management 
infection management
Pre term labour
unknown 
rupture

Answer 30

colposcopy
swabs/specific rx
steroids +/- tocolysis
conservative 
laparotomy/CS

Question 31

planned delivery for suspected or confirmed placenta accreta

Answer 31

CS at 37 weeks
inform blood bank and cross match 6 units of blood
cell salvage should be set up of available

Question 32

post partum haemorrhage how many women

complications

Answer 32

4% of vaginal deliveries

maternal fatigue, feeding difficulties, prolonged hospital stay, delayed lactation, pit infarction, transfusion, haemorrghagic shock, DIC, death

Question 33

PPH definition 
primary 
secondary 
minor
mod
major

Answer 33

>500ml
within 24 hours
>24 hours to 6 weeks
<500ml
500-1500ml
>=1500ml

Question 34

causes for PPH

Answer 34

tone 70%
trauma 20%
tissue 10%
thrombin <1%

Question 35

antenatal risk factors for PPH

Answer 35

anaemia
previous CS
placenta praaevia, parcreta, accrete
previous PPH or retained placenta
multiple pregnancy

Question 36

intrapartum risk factors for PPH

Answer 36

prolonged labour
operative vaginal delivery /CS
retained placenta

Question 37

PPH initial management

Answer 37

uterine massage
5 units IV synctocinon stat
40 units sync in 500mls
hartmanns 125ml/hr

Question 38

persistent PPH management

Answer 38

confirm placenta and membrane comply 
urinary caterer 
500 mcg ergometrine IV
if vaginal/perineal trauma - repair
transfer for EUA
PGF2 - carbaprost/haemoabate 250mcg IM

Question 39

when should ergometrine be avoided

Answer 39

cardiac disease/hypertension