Bleeding in Late Pregnancy Flashcards
What is defined as bleeding in early pregnancy?
<24wks
What is defined as bleeding in late pregnancy (antepartum haemorrhage)?
> =24wks
What are some causes for antepartum haemorrhage?
Placenta previa Placental abruption Local- polyps, cancer, infection Vasa previa- rare Uterine rupture Show Idiopathic (40%)
What is placental abruption?
Separation of a normally implanted placenta partially or totally before birth of the fetus
What are RFs for placental abruption?
Pre-eclampsia/HT Trauma Smoking/Cocaine/Amphetamine Medical- thrombophilias/renal/DM Poly-hydramnios, multiple pregnancy, preterm-PROM Abnormal placenta
What is the rate of recurrence of abruption?
10%
How can placental abruption be categorised?
Revealed
Concealed
What life-threatening condition can occur when placental abruption causes bleeding into the uterine myometrium, pushing the uterus into the peritoneal cavity?
Couvelaire uterus
What are the key clinical features of abruption?
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
How is abruption diagnosed?
Clinically
US can aid
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
How can placenta previa be classified?
Lateral/marginal/incomplete centralis, complete centralis
Grade I-IV
Major/minor-distance from cervix by US
What are the clinical features of placenta previa?
Painless, ‘causeless, recurrently 3T bleeding
Amount of blood variable
Uterus soft non tender
Malpresentations- breech/transverse/oblique
High head
Normal CTG
How is placenta previa diagnosed?
20 week US- anomaly scan Then 32/34 week scan
What should not be performed prior to exclusion of placenta previa?
Vaginal exam
How should major degrees of placenta previa (=<2cm from os/covering os) be delivered?
C section
How should minor degrees of placenta previa (>2cm from os) be delivered?
Consider vaginal delivery
What is placenta accreta?
Placenta invades myometrium
What is placenta percreta?
Placenta has reached serosa
What is placenta accrete associated with?
Severe bleeding
PPH
May have hysterectomy
What are some major RFs for placenta accrete?
Placenta previa
Previous C section (risk increases with no)
What can be the cause of uterine rupture?
Previous C section/uterine surgery
What can uterine rupture cause?
Small or large volume blood loss Intra-partum loss of contractions Obstructed labour Peritonism Fetal head high Fetal distress/IUD Haematuria
What is vasa previa?
Velamentous insertion of cord/succenturate lobe
Fetal vessel wthin membranes
How can vasa previa be diagnosed?
Antenatally
What severe complication cause vasa praevia cause?
Fetal death
What are the clinical features of a local APH?
Small volume Painless Provoking factor Uterus soft, non tender No fetal distress Normally sited placenta
How is placenta previa managed?
Admit IV access-bloods Scan Anti D Steroids Delivery- <2cm C-section at 38-39wks, delivery soon if significant bleeding
When should C-section be carried out at 37-38 weeks in placenta previa?
If there has been prior bleeding in pregnancy or suspected/confirmed placenta accreta
How should placental abruption be managed?
Admit IV access-bloods Resus/manage DIC Delivery viable baby- CS vs Vaginal Paeds Stillbirth- vaginal delivery Anti D Steroids if expectant management
What is the antenatal admission criteria?
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
What do steroids do to fetal lung surfactant production?
Promote production
What effect do steroids have on neonatal respiratory distress syndrome?
Reduce by up to 50% if administered 24-48hrs before delivery
Until what week should steroids be administered?
Wk 36
Only significant effect up to 34 weeks, proven benefit up to 1 week of treatment
What choice of steroid is preferred in antenatal use?
Betamethasone over dexamethasone
What is 1 full course of betamethasone antenatally?
12mg IM x2 injections 12 hours apart
How should suspected cervical causes of bleeding be managed?
Colposcopy
How should suspected infective causes of bleeding be managed?
Swabs/specific treatment
How should bleeding in PTL be managed?
Steroids +- tocolysis
How should vasa previa be managed?
C-section
How should rupture be managed?
Laparotomy
CS
How should delivery be carried out for suspected or confirmed placenta accrete?
C-section at 37 weeks to avoid unplanned pregnancy
MDT involvement
Cross match
Cell salvage should be set up if available
How should antenatal admission with a PV bleed be managed?
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
What are some complications of PPH?
Maternal fatigue Feeding difficulties Prolonged hospital stay Delayed lactation Pituitary infarction Transfusion Haemorrhagic shock DIC Death
What is the incidence of PPH?
Up to 4% of all vaginal deliveries
How is PPH defined?
> 500ml
How is PPH categorised?
Primary- within 24hrs Secondary- >24 hours/6/52 Minor <500ml Moderate 500-1500mk Major PPH >=1500ml
What are the likely aetiologies of PPH?
4 T's Tone 70% Trauma 20% Tissue 10% Thrombin <1%
What are antenatal RFs for PPH?
Anaemia Prv C section Placenta previa, percreta, accrete Prv PPH or retained placenta Multiple pregnancy
What are intrapartum RFs for PPH?
Prolonged labour
Operative vaginal delivery/C section
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
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
What is the non-surgical management of persistent PPH of >1500ml?
Packs and balloons
Tissue sealants
Factor VIIa
Arterial embolisation
What is the surgical management of persistent PPH of >1500ml?
Undersuturing Brace sutures Uterine Artery Ligation Internal Iliac Artery Ligation Hysterectomy
