bleeding in late pregnancy Flashcards
what is antepartum haemorrhage
bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
causes of haemorrhagic mortality in late pregnancy
placental abruption
placenta praaevia
PPH
functions of the placenta
gas transfer
metabolism/waste disposal
hormone production (HPL and hGh-V)
protective filter
differential diagnosis of APH
heavy show
cystitis
haemorrhoids
‘spotting’ APH
staining, streaking, wiping
minor APH
<50 ml settled
major APH
50-1000 ml
no shock
massive APH
> 1000 ml and/or shock
what is placental abruption
separation of a normally implanted placenta, partially or totally, before the birth of the fetus
pathophysiology of placental abruption
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
what is a couvelaire uterus
loosening of the placenta results in bleeding into the myometrium which makes its way into the peritoneal cavity
risk factors for placental abruption
pre-eclampsia/HTN trauma (blunt, forceful) smoking/cocaine/speed thrombophilia/renal disease polyhydramnios multiple pregnancy abnormal placenta
symptoms of placental abruption
severe continuous abdominal pain backache with posterior placenta bleeding preterm labour maternal collapse
signs of placental abruption
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
placental abruption management
resuscitate mother
assess and deliver the baby
manage complications
maternal complications of placental abruption
hypovolaemic shock anaemia PPH renal failure from renal tubular necrosis coagulopathy infection prolonged hospital stay
fetal complications of placental abruption
fetal death hypoxia prematurity SGA growth restriction
what is placenta praaevia
placenta lying directly over the internal os
what is a low lying placenta
placental edge is less than 20 mm from the internal os on transabdominal or transvaginal scanning (after 16 weeks)
anatomically speaking, what is the lower segment of the uterus
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
physiological speaking, what is the lower segment of the uterus
the part of the uterus which does not contract in labour, but passively dilates
metrically speaking, what is the lower segment of the uterus
the part of the uterus which is about 7 cm from the level of the internal os
what is the biggest risk factor for placenta praaevia
previous c-section
symptoms of placenta praaevia
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
signs of placenta praaevia
uterus soft and non-tender presenting part high malpresentations CTG normally normal do not perform vaginal exam until placenta praaevia is excluded
delivery plan for placenta praaevia
c section if placenta covers os or <2 cm away
vaginal delivery if placenta >2 cm from os and no malpresentation
what is placenta accreta
a morbidly adherent placenta (abnormally adherent to uterine wall)
complications of placenta accreta
high risk of maternal death
hysterectomy
definition of uterine rupture
full thickness opening of uterus
risk factors for uterine rupture
previous c-section/uterine surgery
multiparity
use of prostaglandins/syntocinon
obstructed labour
symptoms of uterine rupture
severe abdominal pain
shoulder tip pain
maternal collapse
PV bleeding
uterine rupture signs
intra-partum - loss of contractions acute abdomen PP rises peritonism fetal distress/IUD
what is vasa praaevia
unprotected fetal vessels traverse the membrane below the presenting part over the internal cervical os
risk factors for vasa praaevia
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
what is post partum haemorrhage
blood loss 500 ml or more after birth of baby
primary vs secondary PPH
primary = within 24 hours secondary = >24 hours - 6/52 post delivery
what are the 4T’s of PPH
tone
trauma
tissue
thrombin
intrapartum risk factors for PPH
prolonged labour
operative vaginal delivery
c-section
retained placenta
