Bleeding in Late Pregnancy Flashcards
What is bleeding in early pregnancy defined as?
<24 weeks
What is bleeding in late pregnnacy known as?
antepartum haemorrhage
What is antepartum haemorrhage defined as?
bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
What are the causes of APH?
placenta praevia; placental abruption; local causes; vasa previa; uterine rupture
What is the differential diagnosis of APH?
heavy show; cystitis; haemorrhoids
What is spotting?
staining; streaking or blood spotting noted on underwear or saintary protection
What is a minor haemorrhage in APH?
<50ml
What is a major haemorrhage in APH?
50-1000ml loss with no signs of shock
What is a massive haemorrhage in APH?
> 1000ml and/or chock
What is placental abruption?
separation of a normally implanted placenta- partially or totally before the birth of the fetus
How is a diagnosis of placental abruption made?
Clinically
How common is placental abruption?
1%
What percentage of APH does placental aburption accoutn for?
40%
What happens in placental abruption?
vasospasm followed by arteriole rupture into the decidua which causes tonic contraction and interrupts placental circulation
What is a complication of placental abruption?
couvelaire uterus
what is a couvelaire uterus?
blood from the placental abruption has penetrated the uterine myometrium and is working its way into the peritoneal cavity
What are the risk factors for placental abruption?
pre-eclampsia/HT; trauma; smoking/cocaine/amphetamine; medical- thrombophilia/renal/DM; polyhydramnios; multiple prengnacy;
What are the symptoms of placental abruption?
severe continous abdo pain; bleeding; preterm labour; maternal collapse
What are the signs of placetnal abruption?
uterus LFD; uterine tenderness; woody hard uterus; fetal parts hard to identify; FH- bradycardia/absent; irritable uterus
What is an irritable uterus?
1 contraction/min/ FH abnormality
Why is placental abruption a clinical diagnosis?
USS will fail to detect 75% of aburptions
What is the rate of PPH following placental abruption?
25%
What is placenta praevia?
placenta is partially or totally implanted in the lower uterine segment
What is the lower segment defined as?
part of the uterus below the utero-vesical peritoneal pouch superiorly and internal os inferioyl
What percentage of APH does placenta praevia account for?
20%
What is the biggest risk factor for placenta praeiva?
prev C/S
What are the risk factors for placenta praevia?
prev C/S; asian; smoking; prev TOP; multiparity; >40yo; mulitple pregnnacy; assisted conception; defieinnt endmetrium
What is major praevia?
placenta lies over the internal cervical os
what is minor/partial praevia?
leading edgeo f hte placenta is in the lower uterine segment but not covering hte cervical os
What is the differnece betwen the bleeding seen with placental abruption and with placenta praevia?
in placenta praevia the bleeding is painless
What should not be done before placenta praevia is excluded?
vaginal examination
How is placenta praevia diagnosed?
TVUSS
What is give nfor neuro-protection between 24-32 weeks?
magnesium sulphate
What should couples be told to avoid with expectant mx of placenta praevia?
avoid penetrative sex
When should C/S be done with placenta praevia?
placenta <2cm from cervical os
When can vaginal deliery be done with placental praevia?
placenta >2cm from os and no malpresentation
What is placenta accreta?
morbidly adherent placenta to uterine wall
What increases the risk of placenta accreta?
multiple C/S and placenta praevia
What is placenta accreta known as if placenta is invading myometrium?
increta
What is placenta accreta known if placenta is peentrating uterus to bladder?
precreta
What is the blood loss expected with placenta accreta?
> 3L
What is a Klleihauer test done to asses?
degree of fetomaternal haemorrhage
What is the managemtn of placenta accreta?
prophlyactic internal ilac artery balloon; caesarean hysterectomy
What is the approximate blood volume in pregnnacy?
100ml/kg
What is uterine rupture?
full thickness opening of uterus
What are the risk factors for uterine rupture?
prev C/S/uterine surgery; multiparity; IOL; obstructed labour
What are the symptoms of uterine rupture?
severe abdo pain; shoulder-tip pain; maternal collapse; PV bleeding
What are the signs of uterine rupture?
intra-partum- loss of contractions; acute abdo; presenting part rises; peritnosim; fetal distress
What is vasa praevia?
unprotected fetal vessels traverse the fetal membraens over the interal cervical os
What is seen with artifical rupture of membranes in vasa praevia?
sudden bleeding and fetal bradycardia/ death
What are the risk factors for vasa praevia?
placental anomalies; hx of placental praevia; multiple pregnancy; IVF
What is PPH defined as?
blood loss >=500ml after second stage of labour
What is primary PPH?
within 24hr of delivery
What is secondary PPH?
> 24hrs-6/52 post delivery
What is minor PPH?
500-1000ml without shock
What is major PPH?
> 1000ml or signs of CVS collpse or ongoing bleeding
What are the 4Ts in PPH causes?
tone; trauma; tissue ; thrombin
What are the antenatal PPH?
anaemia; prev C/S; placenta praevia; percreta; prev PPH; multiple pregnancy; polyhydramnios; obesity; macrosomia
What are hte intra-partum RF for PPH?
prolonged labour; operative vaginal delivery; C/S; retianed section
What should be done to prevent PPH?
active mx of thrid stage
What is active mx of the thrid stage of labour?
syntocinon/ syntometrin IM/IV
What are hte measures for minor PPH?
IV access; bloods; obs; IV warmed crystalloid infusion
How can bleeding be stopped in PPH?
uterine massage- bimanual compression; expel clots; IV syntocinon; foleys catheter; ergoemtrine
Who should ergometrine be avoided in?
cardiac disease and HT
What fluids are used in PPH?
crystalloid Hartmann’s
What should be exclusded with secondary PPH?
retained products of conception
Waht is likely to play a role in secodnary PPH?
infection
What are the 3 important things to remmebr in APH?
Kleihauer; anti-D and steroids
