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Bleeding in Late Pregnancy Flashcards

1
Q

What is defined as bleeding in early pregnancy?

A

<24wks

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2
Q

What is defined as bleeding in late pregnancy (antepartum haemorrhage)?

A

> =24wks

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3
Q

What are some causes for antepartum haemorrhage?

A 
Placenta previa
Placental abruption
Local- polyps, cancer, infection
Vasa previa- rare
Uterine rupture
Show
Idiopathic (40%)
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4
Q

What is placental abruption?

A

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

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5
Q

What are RFs for placental abruption?

A 
Pre-eclampsia/HT
Trauma
Smoking/Cocaine/Amphetamine
Medical- thrombophilias/renal/DM
Poly-hydramnios, multiple pregnancy, preterm-PROM
Abnormal placenta
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6
Q

What is the rate of recurrence of abruption?

A

10%

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7
Q

How can placental abruption be categorised?

A

Revealed

Concealed

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8
Q

What life-threatening condition can occur when placental abruption causes bleeding into the uterine myometrium, pushing the uterus into the peritoneal cavity?

A

Couvelaire uterus

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9
Q

What are the key clinical features of abruption?

A 
Small or large volume of blood loss-signs may be inconsistent with revealed blood
Pain
Uterine tenderness/wooden hard
Uterine feels larger
Difficult to palpate fetal parts
CTG
Abnormally frequent contractions
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10
Q

How is abruption diagnosed?

A

Clinically

US can aid

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11
Q

What is placenta previa?

A

Placenta is partially or totally implanted in the lower uterine segment

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12
Q

What is the incidence of placenta previa?

A

5% at anomaly scan

1:200 at term

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13
Q

How can placenta previa be classified?

A

Lateral/marginal/incomplete centralis, complete centralis
Grade I-IV
Major/minor-distance from cervix by US

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14
Q

What are the clinical features of placenta previa?

A

Painless, ‘causeless, recurrently 3T bleeding
Amount of blood variable
Uterus soft non tender
Malpresentations- breech/transverse/oblique
High head
Normal CTG

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15
Q

How is placenta previa diagnosed?

A

20 week US- anomaly scan Then 32/34 week scan

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16
Q

What should not be performed prior to exclusion of placenta previa?

A

Vaginal exam

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17
Q

How should major degrees of placenta previa (=<2cm from os/covering os) be delivered?

A

C section

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18
Q

How should minor degrees of placenta previa (>2cm from os) be delivered?

A

Consider vaginal delivery

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19
Q

What is placenta accreta?

A

Placenta invades myometrium

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20
Q

What is placenta percreta?

A

Placenta has reached serosa

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21
Q

What is placenta accrete associated with?

A

Severe bleeding
PPH
May have hysterectomy

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22
Q

What are some major RFs for placenta accrete?

A

Placenta previa

Previous C section (risk increases with no)

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23
Q

What can be the cause of uterine rupture?

A

Previous C section/uterine surgery

24
Q

What can uterine rupture cause?

A 
Small or large volume blood loss
Intra-partum loss of contractions
Obstructed labour
Peritonism
Fetal head high
Fetal distress/IUD
Haematuria
25
Q

What is vasa previa?

A

Velamentous insertion of cord/succenturate lobe

Fetal vessel wthin membranes

26
Q

How can vasa previa be diagnosed?

A

Antenatally

27
Q

What severe complication cause vasa praevia cause?

A

Fetal death

28
Q

What are the clinical features of a local APH?

A 
Small volume
Painless
Provoking factor
Uterus soft, non tender
No fetal distress
Normally sited placenta
29
Q

How is placenta previa managed?

A 
Admit
IV access-bloods
Scan
Anti D
Steroids
Delivery- <2cm C-section at 38-39wks, delivery soon if significant bleeding
30
Q

When should C-section be carried out at 37-38 weeks in placenta previa?

A

If there has been prior bleeding in pregnancy or suspected/confirmed placenta accreta

31
Q

How should placental abruption be managed?

A 
Admit
IV access-bloods
Resus/manage DIC
Delivery viable baby- CS vs Vaginal
Paeds
Stillbirth- vaginal delivery
Anti D
Steroids if expectant management
32
Q

What is the antenatal admission criteria?

A

Any Hx of acute bleeding 23-32 wks
Recurrent bleeding after 28 wks
Any bleeding after 32 wks
Major placenta previa after 36 wks with no bleeding

33
Q

What do steroids do to fetal lung surfactant production?

A

Promote production

34
Q

What effect do steroids have on neonatal respiratory distress syndrome?

A

Reduce by up to 50% if administered 24-48hrs before delivery

35
Q

Until what week should steroids be administered?

A

Wk 36

Only significant effect up to 34 weeks, proven benefit up to 1 week of treatment

36
Q

What choice of steroid is preferred in antenatal use?

A

Betamethasone over dexamethasone

37
Q

What is 1 full course of betamethasone antenatally?

A

12mg IM x2 injections 12 hours apart

38
Q

How should suspected cervical causes of bleeding be managed?

A

Colposcopy

39
Q

How should suspected infective causes of bleeding be managed?

A

Swabs/specific treatment

40
Q

How should bleeding in PTL be managed?

A

Steroids +- tocolysis

41
Q

How should vasa previa be managed?

A

C-section

42
Q

How should rupture be managed?

A

Laparotomy

CS

43
Q

How should delivery be carried out for suspected or confirmed placenta accrete?

A

C-section at 37 weeks to avoid unplanned pregnancy
MDT involvement
Cross match
Cell salvage should be set up if available

44
Q

How should antenatal admission with a PV bleed be managed?

A

Wide bore access
FBC
Cross match 2-4 units with any bleeding more than 1 tsp.
Kleihauer test- administer anti-D as per protocol if Rh-
Do not give enoxaparin thromboprophylaxis if indicated- TEDS, mobilisation and hydration only

45
Q

What are some complications of PPH?

A 
Maternal fatigue
Feeding difficulties
Prolonged hospital stay
Delayed lactation
Pituitary infarction
Transfusion
Haemorrhagic shock
DIC
Death
46
Q

What is the incidence of PPH?

A

Up to 4% of all vaginal deliveries

47
Q

How is PPH defined?

A

> 500ml

48
Q

How is PPH categorised?

A 
Primary- within 24hrs
Secondary- >24 hours/6/52
Minor <500ml
Moderate 500-1500mk
Major PPH >=1500ml
49
Q

What are the likely aetiologies of PPH?

A 
4 T's
Tone 70%
Trauma 20%
Tissue 10%
Thrombin <1%
50
Q

What are antenatal RFs for PPH?

A 
Anaemia
Prv C section
Placenta previa, percreta, accrete
Prv PPH or retained placenta
Multiple pregnancy
51
Q

What are intrapartum RFs for PPH?

A

Prolonged labour
Operative vaginal delivery/C section
Retained placenta

52
Q

What is the initial management for PPH?

A

Uterine massage
5 units IV Syntocinon stat
40 units Syntocinon in 500ml Hartmanns- 125ml/h

53
Q

What is the management for persistent PPH?

A

Confirm placenta and membranes complete
Urinary catheter
500micrograms Ergometrine IV (avoid if CVD/HT)
If vaginal/perineal/trauma- ensure prompt repair
Help
Maternity Operating Theatre for EUA
PGF2α 250micrograms IM (up to x8)
D/W haematology BTS- blood products required

54
Q

What is the non-surgical management of persistent PPH of >1500ml?

A

Packs and balloons
Tissue sealants
Factor VIIa
Arterial embolisation

55
Q

What is the surgical management of persistent PPH of >1500ml?

A 
Undersuturing
Brace sutures
Uterine Artery Ligation
Internal Iliac Artery Ligation
Hysterectomy

Reproduction (40 decks)

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