bleeding in late pregnancy

Question 1

what is antepartum haemorrhage

Answer 1

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

Question 2

causes of haemorrhagic mortality in late pregnancy

Answer 2

placental abruption
placenta praaevia
PPH

Question 3

functions of the placenta

Answer 3

gas transfer
metabolism/waste disposal
hormone production (HPL and hGh-V)
protective filter

Question 4

differential diagnosis of APH

Answer 4

heavy show
cystitis
haemorrhoids

Question 5

‘spotting’ APH

Answer 5

staining, streaking, wiping

Question 6

minor APH

Answer 6

<50 ml settled

Question 7

major APH

Answer 7

50-1000 ml

no shock

Question 8

massive APH

Answer 8

> 1000 ml and/or shock

Question 9

what is placental abruption

Answer 9

separation of a normally implanted placenta, partially or totally, before the birth of the fetus

Question 10

pathophysiology of placental abruption

Answer 10

vasospasm followed by arteriole rupture into decidua
blood escapes into the amniotic sac or further under the placenta and not myometrium
causes tonic contraction and interrupts placental circulation which causes hypoxia

Question 11

what is a couvelaire uterus

Answer 11

loosening of the placenta results in bleeding into the myometrium which makes its way into the peritoneal cavity

Question 12

risk factors for placental abruption

Answer 12

pre-eclampsia/HTN
trauma (blunt, forceful)
smoking/cocaine/speed 
thrombophilia/renal disease 
polyhydramnios
multiple pregnancy 
abnormal placenta

Question 13

symptoms of placental abruption

Answer 13

severe continuous abdominal pain 
backache with posterior placenta 
bleeding 
preterm labour 
maternal collapse

Question 14

signs of placental abruption

Answer 14

unwell distressed patient 
signs inconsistent with revealed blood 
uterus LFD or normal 
uterine tenderness 
woody hard uterus 
fetal parts hard to identify 
preterm labour 
CTG shows irritably uterus

Question 15

placental abruption management

Answer 15

resuscitate mother
assess and deliver the baby
manage complications

Question 16

maternal complications of placental abruption

Answer 16

hypovolaemic shock 
anaemia 
PPH
renal failure from renal tubular necrosis 
coagulopathy 
infection 
prolonged hospital stay

Question 17

fetal complications of placental abruption

Answer 17

fetal death 
hypoxia 
prematurity 
SGA
growth restriction

Question 18

what is placenta praaevia

Answer 18

placenta lying directly over the internal os

Question 19

what is a low lying placenta

Answer 19

placental edge is less than 20 mm from the internal os on transabdominal or transvaginal scanning (after 16 weeks)

Question 20

anatomically speaking, what is the lower segment of the uterus

Answer 20

the part of the uterus below the utero-vesical peritoneal pouch superiorly and the internal os inferiorly
it is thinner and contains less muscle fibres than upper segment

Question 21

physiological speaking, what is the lower segment of the uterus

Answer 21

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

Question 22

metrically speaking, what is the lower segment of the uterus

Answer 22

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

Question 23

what is the biggest risk factor for placenta praaevia

Answer 23

previous c-section

Question 24

symptoms of placenta praaevia

Answer 24

painless bleeding >24 weeks
usually unprovoked but coitus can trigger bleeding
bleeding can be minor or severe
condition is proportional to amount of bleeding observed

Question 25

signs of placenta praaevia

Answer 25

uterus soft and non-tender 
presenting part high 
malpresentations 
CTG normally normal 
do not perform vaginal exam until placenta praaevia is excluded

Question 26

delivery plan for placenta praaevia

Answer 26

c section if placenta covers os or <2 cm away

vaginal delivery if placenta >2 cm from os and no malpresentation

Question 27

what is placenta accreta

Answer 27

a morbidly adherent placenta (abnormally adherent to uterine wall)

Question 28

complications of placenta accreta

Answer 28

high risk of maternal death

hysterectomy

Question 29

definition of uterine rupture

Answer 29

full thickness opening of uterus

Question 30

risk factors for uterine rupture

Answer 30

previous c-section/uterine surgery
multiparity
use of prostaglandins/syntocinon
obstructed labour

Question 31

symptoms of uterine rupture

Answer 31

severe abdominal pain
shoulder tip pain
maternal collapse
PV bleeding

Question 32

uterine rupture signs

Answer 32

intra-partum - loss of contractions 
acute abdomen 
PP rises 
peritonism 
fetal distress/IUD

Question 33

what is vasa praaevia

Answer 33

unprotected fetal vessels traverse the membrane below the presenting part over the internal cervical os

Question 34

risk factors for vasa praaevia

Answer 34

placental anomalies such as bi-lobed placenta or succenturiate lobes where fetal vessels run through the membranes joining the lobes together
history of low lying placenta in 2nd trimester
multiple pregnancy
IVF

Question 35

what is post partum haemorrhage

Answer 35

blood loss 500 ml or more after birth of baby

Question 36

primary vs secondary PPH

Answer 36

primary = within 24 hours 
secondary = >24 hours - 6/52 post delivery

Question 37

what are the 4T’s of PPH

Answer 37

tone
trauma
tissue
thrombin

Question 38

intrapartum risk factors for PPH

Answer 38

prolonged labour
operative vaginal delivery
c-section
retained placenta