Bleeding in Late Pregnancy Flashcards
bleeding in late pregnancy is identified as bleeding >_ weeks
24
causes of PPH?
atonic uterus
genital tract trauma
don’t give more than _ litres of crystalloid to a pregnant woman as resus
2
the placenta becomes the sole source of baby’s nutrition from _ weeks gestation
6
functions of the placenta?
gas transfer
metabolism/waste disposal
hormone production
prtection
when does APH become PPH?
after 2nd stage of labour
local causes of APH?
cervical ectropion
polyps
cervical cancer
infection eg cervicitis, STI
placental causes of APH?
placenta praevia
placental abruption
what is heavy show?
mucus and blood that comes before labour
DDx of APH?
heavy show
UTI
haemorrhoids
minor APH is
50
major APH is
50 to 100
massive APH is >___ml
1000
shock is present in ___ APH
massive
if the blood from the patient has extended to their feet on the bed it indicates what kind of haemorrhage?
minor to major
define placental abruption
separation of a normally implanted placenta that is partially or totally before birth of the fetus
describe the pattern of pain in placental abruption?
continuous
pathology of placental abruption?
vasospasm -> arteriole rupture into the decidua -> blood escapes into amniotic sac or into myometrium -> causes tonic contraction -> less blood in placenta = hypoxia
placental abruption results in what kind of uterus?
couvelaire (haematoma bruises uterus)
symptoms of PA?
severe continuous abdo pain
backache if posterior placenta
bleeding
preterm labour
risk factors for PA?
hypertensive cause eg PET trauma eg RTA smoking/cocaine/amphetamine thrombophilias renal disease diabetes polyhydramnios multiple pregnancy abnormal placenta previous abruption
signs of PA?
unwell distressed patient uterus large or normal uterine tenderness woody hard uterus fetal parts hard to identify preterm labour with heavy show fetal heart in bradycardia/absent CTG shows irritable uterus
irritable uterus on CTG appears like..
1 contraction a min
fetal heart in tachycardia, loss of variability, presence of decelerations
Ix of PA?
clinical diagnosis FBC clotting factors LFT U+Es crossmatch
Tx of PA
resuscitate mother - fluids, blood, catheter
assess and delivery baby
manage complications - steroids
debrief patients
what MDT members are involved in a category 1 CS?
midwives obstetrician anasthetists neonatal team theatre nurses haematologist
how is FH assessed in PA?
CTG
do USS if undetectable
complications for the mother in PA?
hypovolaemic shock anaemia kidney failure - renal tubular necrosis coagulopathies thromboembolism PPH
complications for fetus in PA?
RDS if lack of steroids given intrauterine death prematurity SGA FGR
how can you prevent PA in some patients?
if APS: LMWH and LDA
smoking cessation
LDA
define minor and major placenta praevia
MINOR: if leading edge of placenta is in the lower uterine segment but not covering the os
MAJOR: placenta lying over the internal os of the cervix - “a low lying cervix”
the __ segment of the uterus is thinner and contains less muscle fibres
lower
the lower segment of the uterus is about _cm from the internal os
7
CS rate in UK?
25-30%
risk factors for placenta praevia?
previous CS previous PP asian smoking previous ToP esp surgical multiparity age ART
what can cause a mother’s endometrium to become deficient?
uterine scar endometritis manual removal of placenta curettage submucous fibroid
scans are done at what gestation to check the placental position?
20 weeks
32 weeks
why should you not do a digital VE in PP?
putting finger into placenta and triggering bleeding
painless bleeding >24 weeks…
PP
describe the bleeding in PP and what can cause it
unprovoked/triggered by coitis
painless
can be spotting or severe
signs of PP
condition proportional to bleeding
uterus soft non tender
presenting part high
baby’s position abnormal
describe CTG in PP
normal
Ix of PP
transvaginal USS
check previous anomaly scans
MRI to exclude placenta accreta
Tx of PP
resus mother
assess baby
conservative mananagement until stable (keep in for 24hrs)
avoid sex
when should you deliver the baby if you spot a PP in a mother?
36 weeks (planned CS)
what extra precautions are taken management wise for Rh negative mothers
kleihauer test
give anti D
how many units of blood are given in placental bleeding emergencies?
4-6 units
what medication is given in advance ifa PP is known?
steroids from 24-35 weeks
MgSO4 from 24-32 weeks
what determines whether you do a vaginal or CS delivery in PP?
CS if placenta <2cm from os
SVD if placenta >2cm from os and baby’s position is fine
define placenta accreta
morbidly adherent placenta
what increases risks of PAcc?
multiple C sections
PP
presentation of PAcc?
severe bleeding
PPH
Tx of PAcc?
prophylactic internal iliac artery balloon
CS hysterectomy
resus for expected blood loss
blood loss of >_ml is expected in PAcc
3l
define uterine rupture
full thickness opening of uterus
risks for uterine rupture?
previous CS
IOL (induced labour)
multiparity
use of PGs/syntocinon
symptoms of uterine rupture
shoulder tip pain from inflam of diaphragm
severe abdo pain
collapse of mum
PV bleeding
why do you get shoulder tip pain in uterine rupture?
inflammation of diaphram (referred)
signs of uterine rupture?
loss of contractions acute abdomen PP loss of uterine contractions peritonism fetal distress or IUD
Tx of uterine rupture
resus - IV fluids
laparotomy if complete rupture/CS
4-6 units blood
anti-D
define vasa praevia
unprotected fetal vessels traverse the fetal membranes over the internal cervical os
Ix of vasa praevia
doppler TA and TV USS
symptoms of VP
sudden bleeding
fetal bradycardia or death
risk factors for VP
placental anomalies
history of PP in 2T
multiple pregnancy
IVF
Tx of VP
steroids from 32 weeks
deliver by elective CS 34-36wks
PPH is blood loss equal to or exceeding ___ml after birth
500
what time frame divides primary and secondary PPH
24hrs (if under = primary)
name the 4 T’s causes of PPH
tone - uterine atony
trauma - vaginal tear, cervical laceration, rupture
tissue - anything left inside
thrombin - coagulopathy?
antenatal risk factors for PPH
anaemia previous CS/PPH/retained placenta multiple pregnancy polyhydramnios big baby or big mother
intrapartum risk factors for PPH
prolonged labour
operative vaginal delivery
CS
retained PPH
Tx of mother with PPH?
syntocinon/syntometrine IM/IV
IV grey/orange cannula for taking bloods and giving warmed crystalloid infusion and blood (6 units)
vitals every 15 mins
what bloods should always be taken in obstetric emergencies?
G+S FBC coag screen LFTs lactate cross match
how often should vitals be assessed in PPH?
every 15 mins
_ units of blood should be given in PPH
6
how can you stop the blood in PPH
uterine massage by bimanual compression expel clots manually 5 units IV syntocinon misoprostol 800mcg PR transexamic acid 0.5-1mg IV balloons eg rusch balloon IR - arterial embolisation
surgical Tx of PPH
brace sutures
uterine artery/IIA ligation
hysterectomy last option
Ix of secondary PPH
USS
common causes of secondary PPH
retained products of conception (RPOC)
infection
