Bleeding in Late Pregnancy

Question 1

What is defined as bleeding in late pregnancy?

Answer 1

Bleeding after 24 weeks

Question 2

Obstetric haemorrhage is a leading cause of maternal death in the UK. True/false?

Answer 2

False - uncommon cause of death

Question 3

What is antepartum haemorrhage?

Answer 3

Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour

Question 4

Give some causes of APH

Answer 4

Placenta praevia
Placental abruption
Local causes (polyps/cervical cancer)
Vasa previa
Uterine rupture

Question 5

What is placental abruption?

Answer 5

The separation of a normally implanted placenta before the birth of the fetus

Question 6

What occurs in placental abruption?

Answer 6

Vasospasm causes blood to escape into the amniotic sac/myometrium
Tonic contraction occurs interrupting placental circulation causing hypoxia

Question 7

Give some risk factors for placental abruption

Answer 7

Pre-eclampsia/hypertension
Trauma
Drug use
Thrombophilia
Polyhydramnios

Question 8

Give some clinical features of placental abruption

Answer 8

Severe continuous abdominal pain
Bleeding
Preterm labour
Uterine tenderness
Woody hard uterus
Fetal bradycardia

Question 9

How should the mother be managed in placental abruption?

Answer 9

Rapid assessment and delivery
2 large bore IV cannulas
FBC/LFT/U+Es/Crossmatch
IV fluid

Question 10

In an emergency how should the fetus be delivered in placental abruption?

Answer 10

Category I C-section

Question 11

Give some potential maternal complications of placental abruption

Answer 11

Hypovolaemic shock
Anaemia
PPH
Renal failure
Infection
Thromboembolism

Question 12

Give some potential fetal complications of placental abruption

Answer 12

Fetal death
Hypoxia
Prematurity
SGA

Question 13

What is placenta praevia?

Answer 13

When the placenta lies directly over the internal os

Question 14

Give some risk factors for placenta praevia

Answer 14

Previous C-section/placenta praevia
Asian
Smoking
Previous surgical TOP
Multiple pregnancy

Question 15

Give some clinical features of placenta praevia

Answer 15

Painless bleeding after 24 weeks (especially post-coital)

Soft non-tender uterus

Question 16

A vaginal examination is indicated in patients with placenta praevia. True/false?

Answer 16

False - should not be performed until excluded

Question 17

What investigation is used to diagnose placenta praevia?

Answer 17

USS

Question 18

How is placenta praevia managed if the woman starts bleeding?

Answer 18

2 large bore IV cannulas
FBC/LFT/U+Es/Crossmatch
Anti-D

Question 19

What can be done to manage the fetus in placenta praevia?

Answer 19

Steroids

Magnesium sulfate

Question 20

How should the baby be delivered in placenta praevia?

Answer 20

C-section if placenta <2cm from cervical os

Vaginal delivery if placenta >2cm from cervical os

Question 21

What is placenta accreta?

Answer 21

A placenta that is morbidly adherent to the uterine wall

Question 22

Give some risk factors for placenta accreta

Answer 22

Placenta praevia

Prior C-section

Question 23

What is it called when the placenta starts invading the myometrium?

Answer 23

Placenta increta

Question 24

What is it called when the placenta starts penetrating the bladder?

Answer 24

Placenta percreta

Question 25

How is placenta accreta managed?

Answer 25

Prophylactic internal iliac artery balloon | C-section and abdominal hysterectomy

Question 26

What occurs in uterine rupture?

Answer 26

Full thickness opening of the uterus

Question 27

Give some risk factors for uterine rupture

Answer 27

Previous C-section Multiparity Obstructed labour

Question 28

Give some clinical features of uterine rupture

Answer 28

Severe abdominal/shoulder-tip pain PV bleeding Loss of contractions Peritonism

Question 29

How is uterine rupture managed?

Answer 29

Urgent C-section and resuscitation

Question 30

What is vasa praevia?

Answer 30

Unprotected fetal vessels traverse fetal membranes over the internal os

Question 31

How is vasa praevia detected?

Answer 31

Doppler USS

Question 32

Give some risk factors for vasa praevia

Answer 32

Placental anomalies Low-lying placenta in second trimester Multiparity IVF

Question 33

How is vasa praevia managed?

Answer 33

Steroids from 32 weeks | Elective C-section

Question 34

What is post partum haemorrhage?

Answer 34

Blood loss >500ml after birth of baby

Question 35

What is the difference between primary and secondary PPH?

Answer 35

``` Primary = within 24hrs of delivery Secondary = from 24hrs - 6 weeks post delivery ```

Question 36

What is the difference between major and minor PPH?

Answer 36

Minor - 500-1000ml blood loss without clinical shock | Major - >1000ml blood loss or clinical shock

Question 37

What are the 4 main causes of PPH?

Answer 37

Tone Trauma Tissue Thrombin

Question 38

Give some antenatal risk factors for PPH

Answer 38

``` Anaemia Previous C-section Placenta praevia Previous PPH Multiple pregnancy ```

Question 39

What can be done to actively manage the third stage in patients with PPH?

Answer 39

Syntometerine IM/IV | Syntocinon (hypertensive patients)

Question 40

What methods can be used to stop bleeding in PPH?

Answer 40

Uterine massage Expel clots Foley's catheter

Question 41

What drugs may be used in PPH to stop bleeding?

Answer 41

Carboprost/Haemabate Misoprostol Tranexamic acid

Question 42

Give some surgical methods that can be used to stop bleeding in PPH

Answer 42

Brace sutures Uterine/internal iliac artery ligation Hysterectomy