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Y3 OBS AND GYNAE > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

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

A

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

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2
Q

List functions of the placenta

A

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

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3
Q

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

A

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

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4
Q

List the main causes of antepartum haemorrhage

A 
Placenta previa
Placental abruption
Local causes (cervical or vaginal)
Vasa previa
Uterine rupture
Indetermined/ unexplained
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5
Q

List local causes of antepartum haemorrhage

A

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

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6
Q

List differential diagnoses of antepartum haemorrhage

A

Heavy show
Cystitis
Haemorrhoids

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7
Q

Define what is meant by minor haemorrhage

A

Blood loss <50ml that has settled

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8
Q

Define what is meant by major haemorrhage

A

Blood loss 50-1000ml, no signs of shock

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9
Q

Define what is meant by massive haemorrhage

A

Blood loss >1000ml and/or signs of shock

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10
Q

What happens in placental abruption?

A

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

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11
Q

Placental abruption is a clinical diagnosis. True/False?

A

True

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12
Q

Outline the pathology behind placental abruption

A

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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13
Q

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

A

Couvelaire uterus

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14
Q

List risk factors for placental abruption

A 
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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15
Q

How do women with placental abruption typically present?

A 
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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16
Q

List signs of placental abruption on CTG

A

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

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17
Q

Outline management options for placenta abruption

A

Resuscitation
Rapid assessment and delivery
Manage complications
Debrief parents

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18
Q

List methods of resuscitation in antepartum haemorrhage

A

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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19
Q

List options for delivery in placental abruption

A

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

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20
Q

List maternal complications of placental abruption

A 
Post-partum haemorrhage (25%)
Hypovolaemic shock
Anaemia, coagulopathy
Renal failure
VTE
Infection
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21
Q

List fetal complications of placental abruption

A

Fetal death, hypoxia, prematurity

SGA and fetal growth restriction

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22
Q

List methods of preventing placental abruption

A

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

23
Q

What is placenta previa?

A

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

24
Q

Define what is meant by the ‘lower uterine segment’

A

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

25
Q

What is the difference between major and minor placenta previa?

A

Major covers part/all of the cervix

Minor does not cover the cervix

26
Q

List risk factors for placenta praevia

A 
Previous C-section
Previous praevia
Asian
Smoking
Age >40 years
Previous TOP
Multiparity/multipregnancy
Deficient endometrium
27
Q

How does placenta previa typically present?

A

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

28
Q

How is placenta previa diagnosed?

A

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

29
Q

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

A

False

Never do vaginal examination until placenta previa is excluded!

30
Q

Outline management options for placenta praevia

A 
Resuscitation
Assess baby and carry out investigations
Delivery plan
Conservative management if stable
Prevent anaemia
31
Q

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

A

If < 2cm from os or covering os, C-section is done

If >2cm from os, vaginal delivery is considered

32
Q

Give options for conservation management in placenta praevia with no bleeding

A 
Advise of symptoms
Advise against sex
Antenatal CCS
MgSO4 for neuroprotection
Consider toxolysis if low-lying placenta
33
Q

What is placenta accreta?

A

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

34
Q

The risk of accreta increases with what?

A

Number of C-sections

Previous placenta praevia

35
Q

Outline management options for placenta accreta

A

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

36
Q

What is uterine rupture?

A

Full thickness opening of uterus

37
Q

The risk of uterine rupture increases with what?

A

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

38
Q

How does uterine rupture present?

A 
Severe abdominal pain
Shoulder tip pain
Maternal collapse 
PV bleeding
Fetal distress
39
Q

Outline management options for uterine rupture

A

Rescuscitation

Consider transfusion

40
Q

What is vasa previa?

A

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

41
Q

How is vasa praevia diagnosed?

A

US with Doppler scan

42
Q

How does vasa praevia present?

A

Acute rupture of membranes with sudden bleeding

Fetal bradycardia/ death

43
Q

The risk of vasa praevia increases with what?

A

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

44
Q

Outline management options for vasa praevia

A

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

45
Q

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

A

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

46
Q

Define the types of PPH

A

Primary - within 24 hours of delivery

Secondary - >24 hours to 6 weeks post-delivery

47
Q

List the four main causes of PPH

A

Tone
Trauma
Tissue
Thrombin

48
Q

List risk factors for PPH

A 
Anaemia
Previous C-sectiob
Previous PPH, placenta praevia, accreta
Previous retained placenta
Polyhydramnios, fetal macrosomia
Multiple pregnancy
Obesity
49
Q

Outline management options for PPH

A

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

50
Q

How is PPH managed initially?

A 
Uterine massage (stop bleeding and expel clots)
IV syntocinon (active management of 3rd stage)
51
Q

What is given IV if PPH persists?

A 
Ergometrine IV 1st line
Carboprost IM
Misoprostal PR
Tranexamic acid IV
EUA in theatre if persistent bleeding
52
Q

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

A

Retained products of conception

53
Q

Outline management options for PPH post delivery

A

Thromboprophylaxis
Manage anaemia IV Fe/oral
Datix and risk management

Y3 OBS AND GYNAE (44 decks)

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