Bleeding in Late Pregnancy Flashcards
What is bleeding in early pregnancy defined as?
Bleeding < 24 weeks
What is antepartum haemorrhage defined as?
Bleeding >24 weeks
What is the placenta made of?
Completely foetal tissue
When is the placental the only source of nutrition from?
6 weeks
What are the functions of the placenta?
- Gas transfer.
- Metabolism/waste disposal.
- Hormone production (HPL and hGh-V).
- Protective ‘filter.’
The placenta is very ________
VASCULAR
What is antepartum haemorrhage defined as?
- 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.
Antepartum means?
Occuring not long before childbirth
List potential causes of APH.
- Placenta Praevia.
- Placental Abruption.
- Local causes - Cervical ectoprion, Polyps, Cervical cancer, Infection e.g. cervicitis - STI
- Vasa previa – rare.
- Uterine rupture.
- Indeterminate/Unexplained.
What is the differential diagnosis of APH?
- Heavy show.
- Cystitis.
- Haemorrhoids.
When asking a patient about ‘spotting’, what should you ask about?
Staining, streaking or blood spotting noted on underwear or sanitary protection
What is minor haemorrhage defined as?
Blood loss less than 50ml that has settled.
What is major haemorrhage defined as?
Blood loss of 50-1000ml, with no signs of clinical shock
What is massive haemorrhage defined as?
Blood loss greater than 1000ml +/or signs of clinical shock.
What is the term ‘abruptio-placentae’ latin for?
Breaking away (denoting a sudden accident).
What is placental abruption?
Separation of a normally implanted placenta – partially or totally before birth of the foetus.
What type of diagnosis is placental abruption?
Clinical diagnosis
What % of pregnancies does placental abruption occur in?
1%
What % of APH cases is placental abruption responsible for?
40%
Outline the pathology of placental abruption.
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.
WHAT ARE THE SYMPTOMS OF PLACENTAL ABRUPTION? (know this !!!)
- 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.
How will a patient with placental abruption appear?
Unwell and distressed
What will the size of the uterus be like in placental abruption?
Either LFD or normal.
How will a uterus feel in placental abruption?
Tender and ‘woody’ hard
What will be difficult to identify in placental abruption?
Foetal parts
What might happen to a woman with placental abruption?
Preterm labour + heavy show
What might foetal HR be like in placental abruption?
Bradycardic/ absent (intrauterine death)
What will a CTG show in placental abruption?
Irritable uterus (1contraction/minute)/ FH abnormality- tachycardia, loss of variability, decelerations)
What is the 1st step in the management of placental abruption?
RESUS OF MOTHER
What should be done in placental abruption, after the mother has been resuscitated?
- Assess and deliver the baby.
- Manage the complications.
- Debrief the parents
Outline the factors which should be considered/addressed out when thinking about maternal resuscitation in placental abruption.
- 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
What should be used to assess foetal HR?
CTG
What should be done if there is no FH?
USS
Is USS useful?
Not very – will fail to detect 3/4 of cases of abruption.
What can be done in terms of delivery in placental abruption?
- urgent delivery by c-section.
- SRM and induction of labour.
- expectant management (only for minor cases; allow steroid cover).
What may the uterus be like in placental abruption?
Couvelaire uterus – haematoma bruised uterus.
List foetal complications that may occur during placental abruption.
- Fetal Death- IUD (14%)
- Hypoxia
- Prematurity
- Small for gestational age and fetal growth restriction
List maternal complications that may occur during placental abruption.
- 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
What condition can placental abruption occur in?
APS - anti phospholipid syndrome
What can be given to women with APS to prevent placental abruption?
LMWH and Low Dose Aspirin.
In people at higher risk of placental abruption (not APS), what can be done to reduce risk?
- Smoking cessation
* Low dose Aspirin