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Reproduction and Sexual Health > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

What is bleeding in early pregnancy defined as?

A

Bleeding < 24 weeks

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2
Q

What is antepartum haemorrhage defined as?

A

Bleeding >24 weeks

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3
Q

What is the placenta made of?

A

Completely foetal tissue

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4
Q

When is the placental the only source of nutrition from?

A

6 weeks

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5
Q

What are the functions of the placenta?

A
  • Gas transfer.
  • Metabolism/waste disposal.
  • Hormone production (HPL and hGh-V).
  • Protective ‘filter.’
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6
Q

The placenta is very ________

A

VASCULAR

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7
Q

What is antepartum haemorrhage defined as?

A
  • Bleeding from the genital tract after 24 weeks gestation and before the end of the 2nd stage of labour.

OR

*Bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.

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8
Q

Antepartum means?

A

Occuring not long before childbirth

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9
Q

List potential causes of APH.

A
  • Placenta Praevia.
  • Placental Abruption.
  • Local causes - Cervical ectoprion, Polyps, Cervical cancer, Infection e.g. cervicitis - STI
  • Vasa previa – rare.
  • Uterine rupture.
  • Indeterminate/Unexplained.
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10
Q

What is the differential diagnosis of APH?

A
  • Heavy show.
  • Cystitis.
  • Haemorrhoids.
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11
Q

When asking a patient about ‘spotting’, what should you ask about?

A

Staining, streaking or blood spotting noted on underwear or sanitary protection

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12
Q

What is minor haemorrhage defined as?

A

Blood loss less than 50ml that has settled.

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13
Q

What is major haemorrhage defined as?

A

Blood loss of 50-1000ml, with no signs of clinical shock

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14
Q

What is massive haemorrhage defined as?

A

Blood loss greater than 1000ml +/or signs of clinical shock.

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15
Q

What is the term ‘abruptio-placentae’ latin for?

A

Breaking away (denoting a sudden accident).

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16
Q

What is placental abruption?

A

Separation of a normally implanted placenta – partially or totally before birth of the foetus.

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17
Q

What type of diagnosis is placental abruption?

A

Clinical diagnosis

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18
Q

What % of pregnancies does placental abruption occur in?

A

1%

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19
Q

What % of APH cases is placental abruption responsible for?

A

40%

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20
Q

Outline the pathology of placental abruption.

A

Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into myometrium.

Causes tonic contraction and interrupts placental circulation which causes hypoxia.

Results in Couvelaire uterus.

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21
Q

WHAT ARE THE SYMPTOMS OF PLACENTAL ABRUPTION? (know this !!!)

A
  • Severe abdominal pain which is continuous.
    (different to labour pain which is intermittent, with contractions)
  • or Backache with posterior placenta.
  • Bleeding (may be concealed).
  • Preterm labour.
  • May present with maternal collapse.
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22
Q

How will a patient with placental abruption appear?

A

Unwell and distressed

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23
Q

What will the size of the uterus be like in placental abruption?

A

Either LFD or normal.

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24
Q

How will a uterus feel in placental abruption?

A

Tender and ‘woody’ hard

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25
Q

What will be difficult to identify in placental abruption?

A

Foetal parts

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26
Q

What might happen to a woman with placental abruption?

A

Preterm labour + heavy show

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27
Q

What might foetal HR be like in placental abruption?

A

Bradycardic/ absent (intrauterine death)

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28
Q

What will a CTG show in placental abruption?

A 
Irritable uterus
(1contraction/minute)/ FH abnormality- tachycardia, loss of variability, decelerations)
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29
Q

What is the 1st step in the management of placental abruption?

A

RESUS OF MOTHER

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30
Q

What should be done in placental abruption, after the mother has been resuscitated?

A
  • Assess and deliver the baby.
  • Manage the complications.
  • Debrief the parents
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31
Q

Outline the factors which should be considered/addressed out when thinking about maternal resuscitation in placental abruption.

A
  • Communication (MW, Obstetrics, Anaesthetists, NNU, Theatre, Haematologist
  • 2 Large bore IV access, FBC,clotting, LFT U& E ,Xmatch 4-6 units RBC ,Kleihauer (esp. if mother is Rh-ve)
  • IV fluids (care with PET as don’t want to cause pulmonary oedema)
  • Catheterise- hrly urine volumes
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32
Q

What should be used to assess foetal HR?

A

CTG

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33
Q

What should be done if there is no FH?

A

USS

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34
Q

Is USS useful?

A

Not very – will fail to detect 3/4 of cases of abruption.

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35
Q

What can be done in terms of delivery in placental abruption?

A
  • urgent delivery by c-section.
  • SRM and induction of labour.
  • expectant management (only for minor cases; allow steroid cover).
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36
Q

What may the uterus be like in placental abruption?

A

Couvelaire uterus – haematoma bruised uterus.

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37
Q

List foetal complications that may occur during placental abruption.

A
  • Fetal Death- IUD (14%)
  • Hypoxia
  • Prematurity
  • Small for gestational age and fetal growth restriction
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38
Q

List maternal complications that may occur during placental abruption.

A
  • Hypovolaemic shock
  • Anaemia
  • PPH (25%)
  • Renal failure from renal tubular necrosis
  • Coagulopathy (give FFP, cryoprecipitate)
  • Infection
  • Prolonged hospital stay Psychological sequelae
  • Complications of blood transfusion
  • Thromboembolism
  • Mortality rare
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39
Q

What condition can placental abruption occur in?

A

APS - anti phospholipid syndrome

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40
Q

What can be given to women with APS to prevent placental abruption?

A

LMWH and Low Dose Aspirin.

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41
Q

In people at higher risk of placental abruption (not APS), what can be done to reduce risk?

A
  • Smoking cessation

* Low dose Aspirin

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42
Q

What is placenta praaevia?

A

Where the placenta is partially or totally implanted in the lower uterine segment

Placenta covers cervix so obstructs the birth canal

43
Q

What is placenta praaevia known colloquially as?

A

‘low lying placenta’

44
Q

Anatomically, what is the lower segment of the uterus?

A

The part of the uterus below the utero-vesical peritoneal pouch superiorly, and the internal os inferiorly.
The thinner part of the uterus, containing less muscle fibres than the upper segment.

45
Q

Physiologically, what is the lower segment of the uterus

A

The part of the uterus which does not contract in labour but passively dilates

46
Q

Metrically, what is the lower segment of the uterus

A

The part of the uterus which is about 7cm from the level of the internal os.

47
Q

What % of cases of APH does placenta praaevia account for?

48
Q

List some risk factors for placenta praaevia.

A

• Previous c/section (1 C/S OR 2.2 ; 2C/S OR 4.1; 3 C/S OR 22.4 )
• Previous placenta praevia
• Asian
• Smoking
• Previous termination of pregnancy
• Multiparity
• Advanced maternal age (>40 years)
• Multiple pregnancy
• Assisted conception
• Deficient endometrium due to presence or history of:
– uterine scar, endometritis ,manual removal of placenta ,curettage , submucous fibroid

49
Q

How is placenta praevia classified?

A

By ultrasound imaging, according to what is relevant clinically

50
Q

What are the 2 main types of placenta praevia?

A

Major praevia: if the placenta lies over the internal cervical os.

Minor or partial praevia: if the leading edge of the placenta is in the lower uterine segment, but not covering the cervical os.

51
Q

What are the symptoms of placenta praevia?

A
  • Painless bleeding at >24weeks.
  • Usually unprovoked, but coitus can trigger bleeding.
  • Bleeding can be minor (e.g. spotting) or severe).
52
Q

What is the amount of bleeding in placenta praaevia proportional to?

A

The patients condition

53
Q

How does the uterus in placenta praaevia feel?

A

Soft + non-tender

54
Q

What is the presenting part in placenta praevia like?

55
Q

What is presentation in placental praaevia like?

A

There is often malpresentation – breech/transverse/oblique

56
Q

A CTG in placenta praaevia is abnormal

A

FALSE - normal

57
Q

What must you NOT do to a patient until placenta praevia is excluded?

A

Vaginal exam

58
Q

What type of exam may be useful in placenta praaevia?

59
Q

How is placenta praevia diagnosed?

A

Ultrasound – transvaginal USS for diagnosis

60
Q

What needs to be excluded in placenta praevia? How?

A

Placenta accreta – with MRI

61
Q

Outline the general principles of management of placental praevia.

A
  • Resuscitation of mother: ABC.
  • Assess baby.
  • Investigations.
  • Conservative management if stable.
  • —- inpatient for at least 24hrs until bleeding has ceased.
  • Delivery plan at/near term.
62
Q

When is anti D given?

A

If resus -ve mother

63
Q

When should steroids be given in placenta praevia?

A

24-36+6 weeks

64
Q

As well as steroids, what else should be given in placental praaevia?

A

MgSO4 – at 24-32weeks for neuro-protection if planning delivery

65
Q

In placenta praevia, C section should be carried out if …

A

If placenta is <2cm from cervical os (make sure a consultant is present).

66
Q

In placenta praevia, vaginal delivery should be carried out if …

A

If placenta is >2cm from os and no malpresentation

67
Q

What is placenta accreta?

A

A morbidly adherent placenta; abnormally adherent to the uterine walls

68
Q

If placenta accreta is invading the myometrium, what is this called

A

Placenta increta

69
Q

If placenta accreta is invading the uterus to bladder, what is this called?

A

Placenta percreta

70
Q

Outline the management of placenta accreta.

A
  • Prophylactic internal iliac artery balloon.
  • Caesarean hysterectomy.
  • Blood loss >3l expected.
  • Conservative mx (+ methotrexate (to get rid of placenta)).
71
Q

What is uterine rupture?

A

Full thickness opening of the uterus

72
Q

What are the risk factors for uterine rupture?

A
  • Previous c-section/uterine surgery e.g. myomectomy.
  • Multiparity and use of prostaglandins/syntocinon increase risk.
  • Obstructed labour.
73
Q

What are the symptoms of uterine rupture?

A
  • Severe abdominal pain.
  • Shoulder tip pain.
  • Maternal collapse.
  • PV bleeding.
74
Q

What are the signs of uterine rupture?

A
  • Intra-partum – loss of contractions.
  • Acute abdomen.
  • Presenting part rises.
  • Loss of uterine contractions.
  • Peritonism.
  • Foetal distress/IUD.
75
Q

Outline the management of uterine rupture.

A
  • Urgent Resuscitation & Surgical management
  • Communication (MW, Obstetrics, Anaesthetists, NNU, Theatre, Haematologist)
  • 2 Large bore IV access (grey or orange cannula)
  • FBC, clotting, LFT, U& E , Kleihauer (if Rh Neg)
  • Xmatch 4-6 units RBC
  • May need Major Haemorrhage protocol
  • IV fluids or transfuse
  • Anti D (if Rh Neg)
76
Q

What is vasa praevia?

A

Unprotected fetal vessels traverses the fetal membranes over the internal cervical os.

77
Q

How is vasa praevia identified?

A

USS with doppler

78
Q

What is the danger with vasa praevia?

A

ARM, sudden bleeding and fetal bradycardia/death

79
Q

What is the mortality with vasa praevia?

80
Q

What are the risk factors for vasa praevia?

A
  • Placental anomalies such as a bilobed placenta or succenturiate lobes where the foetal vessels run through the membranes joining the separate lobes together.
  • A history of low-lying placenta in the second trimester.
  • Multiple pregnancy
  • In vitro fertilisation (incidence of 1 in 300)
81
Q

List cervical causes of APH (antepartum haemorrhage)

A
  • Ectropion.
  • Polyp.
  • Carcinoma.
82
Q

What is PPH defined as?

A

Blood loss equal to or exceeding 500ml after the birth of the baby

83
Q

When is PPH defined as ‘primary’?

A

Within 24 hours of delivery

84
Q

When is PPH defined as ‘secondary’?

A

> 24h - 6/52 post-delivery

85
Q

How much blood loss is normal during labour?

A

100mls per kg

86
Q

What is blood loss during labour proportional to?

A

Maternal weight

87
Q

During labour, what volume of blood loss is defined as ‘minor’?

A

500-1000 mls with no clinical signs of shock

88
Q

During labour, what volume of blood loss is defined as ‘major’?

A

> 1000 mls with clinical signs of shock or ongoing bleeding

89
Q

What can the causes of PPH be remembered as? What are they?

A

4 T’s

  • Tone 70%
  • Trauma 20%
  • Tissue 10%
  • Thrombin <1%
90
Q

Can you prevent PPH?

91
Q

What are the risk factors for PPH?

A
  • Anaemia
  • Previous c section
  • Placenta praevia/accrete
  • Previous PPH
  • Previous retained placenta
  • Multiple pregnancy
  • Polyhydramnios
  • Obesity
  • Foetal macrosomnia
92
Q

To help in preventing PPH, intrapartum risk factors should be identified. What are these?

A
  • Prolonged labour.
  • Operative vaginal delivery.
  • Caesarean section.
  • Retained placenta.
93
Q

How should 3rd stage of labour be managed to help prevent PPH?

A

Give the mother Syntocinon/syntometrine IM/IV

94
Q

Outline the management of minor PPH (<1000 mls - clinical shock).

A
  • IV access – one 14 gauge cannula
  • Gravidity + parity
  • FBC + coagulation screen + fibrinogen
  • Obs – pulse, resp rate, BP recording every 15 mins
  • IV warmed crystalloid infusion
95
Q

How can the bleeding in PPH be stopped?

A
  • Uterine massage- bimanual compression

* Expel clots

96
Q

What should be done after the bleeding is stopped in PPH?

A
  • 5 units IV Syntocinon stat 40 units
  • Syntocinon in 500ml Hartmanns - 125 ml/h
  • 500mcg Ergometrine IV
  • Foleys Catheter
97
Q

Do most cases of PPH respond to treatment?

98
Q

List 3 non-surgical methods of stopping bleeding in PPH.

A
  • Packs + balloons – (rusch balloon/bakri balloon)
  • Tissue sealants
  • Arterial embolization
99
Q

List 4 surgical methods of stopping bleeding in PPH.

A
  • Undersuturing
  • Brace sutures – b lynch suture
  • Uterine artery ligation
  • Hyserectomy
100
Q

What blood type should be considered in life threatening haemorrhage?

A

O - ve (this blood type covers all bases)

101
Q

Outline the main features of fluid replacement in PPH.

A
  • 2 Large bore IV access
  • Rapid fluid resuscitation - crystalloid Hartmann’s, 0.9% N/Saline
  • Blood transfusion early
  • Consider O -ve blood if life threatening haemorrhage
  • If DIC/coagulopathy – FFP, cryoprecipitate, platelets
  • Use Blood warmer
  • Cell saver
102
Q

What is secondary PPH defined as?

A

Bleeding >24hrs-6 weeks postnatally

103
Q

What MUST be excluded in a female with secondary PPH?

A

RPOC (retained products of conception) with USS

104
Q

What 2 things must you remember for APH?

A

Kleihauer
+
Anti-D & Steroids

Reproduction and Sexual Health (51 decks)

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