Bleeding in Late Pregnancy Flashcards
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
List functions of the placenta
Gas transfer
Metabolism/ waste disposal
Hormone production (HPL + hGV-V)
Protective filter
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
List the main causes of antepartum haemorrhage
Placenta previa Placental abruption Local causes (cervical or vaginal) Vasa previa Uterine rupture Indetermined/ unexplained
List local causes of antepartum haemorrhage
Cervical ectropion
Polyps
Cervical cancer
Infection e.g. cervicitis - STI
List differential diagnoses of antepartum haemorrhage
Heavy show
Cystitis
Haemorrhoids
Define what is meant by minor haemorrhage
Blood loss <50ml that has settled
Define what is meant by major haemorrhage
Blood loss 50-1000ml, no signs of shock
Define what is meant by massive haemorrhage
Blood loss >1000ml and/or signs of shock
What happens in placental abruption?
Separation of normally implanted placenta from the uterine wall - partially or totally before birth of fetus
Placental abruption is a clinical diagnosis. True/False?
True
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
What is the clinical term for the type of uterus formed in placental abruption?`
Couvelaire uterus
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
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
List signs of placental abruption on CTG
Irritable uterus
FH abnormality (bradycardia/ absent)
Loss of variability
Decelerations
Outline management options for placenta abruption
Resuscitation
Rapid assessment and delivery
Manage complications
Debrief parents
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
List options for delivery in placental abruption
Urgent by LSCS
ARM and induction of labour
Expectant management for minor (steroid cover)
List maternal complications of placental abruption
Post-partum haemorrhage (25%) Hypovolaemic shock Anaemia, coagulopathy Renal failure VTE Infection
List fetal complications of placental abruption
Fetal death, hypoxia, prematurity
SGA and fetal growth restriction
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
