Bleeding in late pregnancy Flashcards
when is bleeding in early pregnancy
<24 weeks
when is bleeding in late pregnancy (antepartum haemorrhage) in the uk
> and equal to 24 hours
functions of the placenta
sole source of nutrition form 6 weeks gas transfer mtabolism/waste disposal hormone production protective filter
definition of antepartum haemorrhage
bleeding form the genital tract after 24 weeks of gestation
causes of APH
placenta previa 20% placental abruption 30% local causes such as polyps, cancer, infection vasa previa uterine rupture
what is the most comments cause of APH
idiopathic
what is placental abruption
separation of a normally implanted placenta partially or totally before the birth of the fetus
risk factors for placental abruption
PET/hypertension trauma smoking/cocaine/amphetamins medical such as thromboembolic/renal/DM polyhydraminios, multiple pregnancy, preterm PROM abnormal placenta recurrence rate 10%
what are the two types of placental abruption
concealed
revealed
what are the clinical features of placental abruption
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
ix for placental abruption
CTG
what is placental previa
placenta is partially or totally implanted in the lower uterine segment
incidence of placenta previa
5% at anomaly scan
1:200 at term
classifications of placenta previa old and new
old - lateral/marginal/incomplete centralis and complete centralis
major - over the uterus completely or slightly over the uterus
minor - not over the uterus
clinical signs and symptoms of placenta previa
CTG readings
painless recurrent third trimester bleeding
amount of blood variable
uterus soft and non tender
malpositions - breech, transverse, oblique
high head
CTG usually normal
dx of placenta previa
US - scan for this at 20 weeks then a scan at 32/34 weeks
what should not be done until placenta previa has been excluded
vaginal exam
types of delivery with placenta previa
major <2cm from os/covering os -> CS
minor >2cm from os -> vaginal delivery
what is placenta accreta
placenta invades myometrium
what are the major risk factors for placenta accreta
placenta previa and prior cs
what can happen during uterine rupture
what is the common cause
small or a large volume intra partum - loss of contractions obstructed labour fetal head high fetal distress
previous CS/uterine surgery
what is vasa praevia
some of the babies vessels are run across and are unsupported by the placenta so are at risk of rupture
dx of vasa praaevia
can be dx antenatally
local causes of APH signs
small volume painless provoking factor uterus soft and non tender no fetal distress normally sited placenta
management of APH
ABCDE for mums safety
fetal safety
management for placenta previa
admit IV access, blood tests/cross match scan anti D steroids delivery
delivery in placenta preview
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
antenatal admission criteria and the minimum stay for east
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
steroids are given why
how
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
cervical causes management infection management Pre term labour unknown rupture
colposcopy swabs/specific rx steroids +/- tocolysis conservative laparotomy/CS
planned delivery for suspected or confirmed placenta accreta
CS at 37 weeks
inform blood bank and cross match 6 units of blood
cell salvage should be set up of available
post partum haemorrhage how many women
complications
4% of vaginal deliveries
maternal fatigue, feeding difficulties, prolonged hospital stay, delayed lactation, pit infarction, transfusion, haemorrghagic shock, DIC, death
PPH definition primary secondary minor mod major
>500ml within 24 hours >24 hours to 6 weeks <500ml 500-1500ml >=1500ml
causes for PPH
tone 70%
trauma 20%
tissue 10%
thrombin <1%
antenatal risk factors for PPH
anaemia previous CS placenta praaevia, parcreta, accrete previous PPH or retained placenta multiple pregnancy
intrapartum risk factors for PPH
prolonged labour
operative vaginal delivery /CS
retained placenta
PPH initial management
uterine massage
5 units IV synctocinon stat
40 units sync in 500mls
hartmanns 125ml/hr
persistent PPH management
confirm placenta and membrane comply urinary caterer 500 mcg ergometrine IV if vaginal/perineal trauma - repair transfer for EUA PGF2 - carbaprost/haemoabate 250mcg IM
when should ergometrine be avoided
cardiac disease/hypertension
