Bleeding in Late Pregnancy Flashcards by Kerry Hendrie

What is the cut-off for bleeding classed as being in early and late pregnancy?

Bleeding from 24 weeks gestation onwards is classed as bleeding in late pregnancy

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List functions of the placenta

Gas transfer
Metabolism/ waste disposal
Hormone production (HPL + hGV-V)
Protective filter

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Antepartum haemorrhage is defined as bleeding from the genital tract after __ weeks gestation

Antepartum haemorrhage is defined as bleeding from the genital tract after 24 weeks gestation

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List the main causes of antepartum haemorrhage

Placenta previa
Placental abruption
Local causes (cervical or vaginal)
Vasa previa
Uterine rupture
Indetermined/ unexplained

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List local causes of antepartum haemorrhage

Cervical ectropion
Polyps
Cervical cancer
Infection e.g. cervicitis - STI

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List differential diagnoses of antepartum haemorrhage

Heavy show
Cystitis
Haemorrhoids

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Define what is meant by minor haemorrhage

Blood loss <50ml that has settled

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Define what is meant by major haemorrhage

Blood loss 50-1000ml, no signs of shock

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Define what is meant by massive haemorrhage

Blood loss >1000ml and/or signs of shock

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What happens in placental abruption?

Separation of normally implanted placenta from the uterine wall - partially or totally before birth of fetus

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Placental abruption is a clinical diagnosis. True/False?

True

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Outline the pathology behind placental abruption

Vasospasm followed by arteriole rupture into decidua, blood escapes into amniotic sac or further under placenta and into myometrium
Causes tonic contraction and interrupts placental circulation which causes hypoxia

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What is the clinical term for the type of uterus formed in placental abruption?`

Couvelaire uterus

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List risk factors for placental abruption

Pre-eclampsia/hypertension
Polyhydramnios
Trauma
Illicit drugs, smoking, alcohol
Abnormally formed placenta
Previous abruption
Medical thrombophilias/renal disease/ DM
Multiple pregnancy, preterm pregnancy

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How do women with placental abruption typically present?

Sudden severe CONTINUOUS abdo pain
Radiation to back (posterior placenta)
Vaginal bleeding (my be concealed)
Uterine tenderness, woody hard uterus
Contractions

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List signs of placental abruption on CTG

Irritable uterus
FH abnormality (bradycardia/ absent)
Loss of variability
Decelerations

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Outline management options for placenta abruption

Resuscitation
Rapid assessment and delivery
Manage complications
Debrief parents

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List methods of resuscitation in antepartum haemorrhage

2 large bore IV access and IV fluids
FBC, clotting, LFT, U+E, X match 4-6U RBC
Kleihaeuer and Anti-D if Rh-
Catheterisation

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List options for delivery in placental abruption

Urgent by LSCS
ARM and induction of labour
Expectant management for minor (steroid cover)

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List maternal complications of placental abruption

Post-partum haemorrhage (25%)
Hypovolaemic shock
Anaemia, coagulopathy
Renal failure
VTE
Infection

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List fetal complications of placental abruption

Fetal death, hypoxia, prematurity

SGA and fetal growth restriction

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List methods of preventing placental abruption

APS - give LMWH and low dose aspirin
Smoking cessation
Low dose aspirin

What is placenta previa?

Placenta is partially or totally implanted in the lower uterine segment
Placenta <20mm from internal os on TVUS

Define what is meant by the ‘lower uterine segment’

Thinner part of the uterus and less muscle fibres
Part of uterus does not contract but dilates
Part of uterus around 7cm from internal os

What is the difference between major and minor placenta previa?

Major covers part/all of the cervix | Minor does not cover the cervix

List risk factors for placenta praevia

``` Previous C-section Previous praevia Asian Smoking Age >40 years Previous TOP Multiparity/multipregnancy Deficient endometrium ```

How does placenta previa typically present?

Painless recurrent bleeding, typically 3rd trimester Usually unprovoked but coitus can trigger Malpresentations common, presenting part high Soft non-tender uterus

How is placenta previa diagnosed?

Trans-vaginal ultrasound scan Anomaly scan checked for "low-lying placenta" MRI for exclusion of placenta accreta CTG normal

A vaginal examination is mandatory in placenta previa. True/False?

False | Never do vaginal examination until placenta previa is excluded!

Outline management options for placenta praevia

``` Resuscitation Assess baby and carry out investigations Delivery plan Conservative management if stable Prevent anaemia ```

How does placenta previa affect the type of delivery of a baby?

If < 2cm from os or covering os, C-section is done | If >2cm from os, vaginal delivery is considered

Give options for conservation management in placenta praevia with no bleeding

``` Advise of symptoms Advise against sex Antenatal CCS MgSO4 for neuroprotection Consider toxolysis if low-lying placenta ```

What is placenta accreta?

Placenta abnormally adherent to uterine wall, invades myometrium causing severe bleeding

The risk of accreta increases with what?

Number of C-sections | Previous placenta praevia

Outline management options for placenta accreta

Prophylactic internal iliac artery balloon Caesarean hysterectomy Blood loss >3l expected Conservative management (+methotrexate)

What is uterine rupture?

Full thickness opening of uterus

The risk of uterine rupture increases with what?

Previous C-section/ uterine surgery Multiparity and use of prostaglandins/ syntocinon Obstructed labour

How does uterine rupture present?

``` Severe abdominal pain Shoulder tip pain Maternal collapse PV bleeding Fetal distress ```

Outline management options for uterine rupture

Rescuscitation | Consider transfusion

What is vasa previa?

Unprotected foetal vessels cross near internal os, causing foetal blood loss if ruptured

How is vasa praevia diagnosed?

US with Doppler scan

How does vasa praevia present?

Acute rupture of membranes with sudden bleeding | Fetal bradycardia/ death

The risk of vasa praevia increases with what?

Placental anomalies History of low-lying placenta in 2nd trimester Multiple pregnancy IVF

Outline management options for vasa praevia

Antenatal diagnosis Steroids from 32 weeks Consider elective delivery Emergency c-section and neonatal resuscitation

Define post-partum haemorrhage, with respect to the amount of blood loss

Blood loss equal to or >500ml after birth of baby Minor: 500ml - 1000ml without shock Major: more than 1000ml or signs of CV collapse or ongoing bleeding

Define the types of PPH

Primary - within 24 hours of delivery | Secondary - >24 hours to 6 weeks post-delivery

List the four main causes of PPH

Tone Trauma Tissue Thrombin

List risk factors for PPH

``` Anaemia Previous C-sectiob Previous PPH, placenta praevia, accreta Previous retained placenta Polyhydramnios, fetal macrosomia Multiple pregnancy Obesity ```

Outline management options for PPH

Resuscitation, carry out obs Stop bleeding Fluid replacement, early blood transfusion, oxygen Active management of 3rd stage

How is PPH managed initially?

``` Uterine massage (stop bleeding and expel clots) IV syntocinon (active management of 3rd stage) ```

What is given IV if PPH persists?

``` Ergometrine IV 1st line Carboprost IM Misoprostal PR Tranexamic acid IV EUA in theatre if persistent bleeding ```

If PPH is classes as secondary, what needs to be excluded?

Retained products of conception

Outline management options for PPH post delivery

Thromboprophylaxis Manage anaemia IV Fe/oral Datix and risk management