Bleeding in Late Pregnancy Flashcards
What is defined as bleeding in late pregnancy?
Bleeding after 24 weeks
Obstetric haemorrhage is a leading cause of maternal death in the UK. True/false?
False - uncommon cause of death
What is antepartum haemorrhage?
Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
Give some causes of APH
Placenta praevia Placental abruption Local causes (polyps/cervical cancer) Vasa previa Uterine rupture
What is placental abruption?
The separation of a normally implanted placenta before the birth of the fetus
What occurs in placental abruption?
Vasospasm causes blood to escape into the amniotic sac/myometrium
Tonic contraction occurs interrupting placental circulation causing hypoxia
Give some risk factors for placental abruption
Pre-eclampsia/hypertension Trauma Drug use Thrombophilia Polyhydramnios
Give some clinical features of placental abruption
Severe continuous abdominal pain Bleeding Preterm labour Uterine tenderness Woody hard uterus Fetal bradycardia
How should the mother be managed in placental abruption?
Rapid assessment and delivery
2 large bore IV cannulas
FBC/LFT/U+Es/Crossmatch
IV fluid
In an emergency how should the fetus be delivered in placental abruption?
Category I C-section
Give some potential maternal complications of placental abruption
Hypovolaemic shock Anaemia PPH Renal failure Infection Thromboembolism
Give some potential fetal complications of placental abruption
Fetal death
Hypoxia
Prematurity
SGA
What is placenta praevia?
When the placenta lies directly over the internal os
Give some risk factors for placenta praevia
Previous C-section/placenta praevia Asian Smoking Previous surgical TOP Multiple pregnancy
Give some clinical features of placenta praevia
Painless bleeding after 24 weeks (especially post-coital)
Soft non-tender uterus
A vaginal examination is indicated in patients with placenta praevia. True/false?
False - should not be performed until excluded
What investigation is used to diagnose placenta praevia?
USS
How is placenta praevia managed if the woman starts bleeding?
2 large bore IV cannulas
FBC/LFT/U+Es/Crossmatch
Anti-D
What can be done to manage the fetus in placenta praevia?
Steroids
Magnesium sulfate
How should the baby be delivered in placenta praevia?
C-section if placenta <2cm from cervical os
Vaginal delivery if placenta >2cm from cervical os
What is placenta accreta?
A placenta that is morbidly adherent to the uterine wall
Give some risk factors for placenta accreta
Placenta praevia
Prior C-section
What is it called when the placenta starts invading the myometrium?
Placenta increta
What is it called when the placenta starts penetrating the bladder?
Placenta percreta
How is placenta accreta managed?
Prophylactic internal iliac artery balloon
C-section and abdominal hysterectomy
What occurs in uterine rupture?
Full thickness opening of the uterus
Give some risk factors for uterine rupture
Previous C-section
Multiparity
Obstructed labour
Give some clinical features of uterine rupture
Severe abdominal/shoulder-tip pain
PV bleeding
Loss of contractions
Peritonism
How is uterine rupture managed?
Urgent C-section and resuscitation
What is vasa praevia?
Unprotected fetal vessels traverse fetal membranes over the internal os
How is vasa praevia detected?
Doppler USS
Give some risk factors for vasa praevia
Placental anomalies
Low-lying placenta in second trimester
Multiparity
IVF
How is vasa praevia managed?
Steroids from 32 weeks
Elective C-section
What is post partum haemorrhage?
Blood loss >500ml after birth of baby
What is the difference between primary and secondary PPH?
Primary = within 24hrs of delivery Secondary = from 24hrs - 6 weeks post delivery
What is the difference between major and minor PPH?
Minor - 500-1000ml blood loss without clinical shock
Major - >1000ml blood loss or clinical shock
What are the 4 main causes of PPH?
Tone
Trauma
Tissue
Thrombin
Give some antenatal risk factors for PPH
Anaemia Previous C-section Placenta praevia Previous PPH Multiple pregnancy
What can be done to actively manage the third stage in patients with PPH?
Syntometerine IM/IV
Syntocinon (hypertensive patients)
What methods can be used to stop bleeding in PPH?
Uterine massage
Expel clots
Foley’s catheter
What drugs may be used in PPH to stop bleeding?
Carboprost/Haemabate
Misoprostol
Tranexamic acid
Give some surgical methods that can be used to stop bleeding in PPH
Brace sutures
Uterine/internal iliac artery ligation
Hysterectomy
