Bleeding in Late Pregnancy

Question 1

What is antepartum haemorrhage?

Answer 1

Bleeding >24 weeks gestation to before the end of stage 2 labour

Question 2

What is placental abruption?

Answer 2

This is when the normally implanted placenta becomes removed from the uterine wall (detaches) before or during the birth of the baby.

Question 3

How does placental abruption occur?

Answer 3

Vaso spasm results in compromise of the placenta. There is rupture of arteriole and bleeding into the decidua. It can then either bleed into the amniotic sac or into the myometrium

Question 4

What can placental abruption cause in the foetus?

Answer 4

Distress, hypoxia and IUD

Question 5

What is a Couvelaire’s uterus?

Answer 5

When there is externsive bleeding into to myometrium resulting in haematoma formation

Question 6

How will a placental abruption present?

Answer 6

continuous severe abdominal pain (may be back pain if posterior placenta)
hard woody uterus
uterine tenderness
bleeding (although can be concealed)
maternal collapse
pre-term ROM

Question 7

What are the signs of placental abruption?

Answer 7

Large for dates, uterine tenderness, hard, woody uterus, PROM, foetal parts are difficult to identify

Question 8

What will a CTG show in placental abruption?

Answer 8

irritable uterus (1 contraction/min) plus abnormal FHR (bradycardia or absent)

Question 9

What should be done if FHR is not detected on CTG?

Answer 9

USS

Question 10

Is USS a good way of diagnosing placental abruption?

Answer 10

No - it will miss 3/4

Question 11

How do you manage a placental abruption?

Answer 11

Stabilise and resus the mother, urgent CS

Question 12

How should you resus the mother in placental abruption?

Answer 12

IV fluids (beware if PET)
1 Large bore catheters
FBC, LFTs, Coag, U&E, Xmatch
4-6 units of RBC
Kleihauer's test +/- anti-d antibodies

Question 13

How often will PPH and IUD occur in placental abruption?

Answer 13

PPH = 25%
IUD = 14%

Question 14

What is placenta praevia?

Answer 14

This is when the placenta covers the internal cervical os - LLP is when the placenta <2cm from the os

Question 15

What are some risk factors for placenta praevia?

Answer 15

Previous placenta praevia, C-sections (increases with number), smoking, increased age, deficient endometrium, IVF

Question 16

How will placenta praevia be detected?

Answer 16

It is usually picked up at the MidT anomaly scan and can then be monitored.
It will be monitored at 32 and 36 weeks via TVUS to assess

Question 17

When should an MRI be carried out?

Answer 17

If suspecting placenta accreta

Question 18

How might placenta praevia present?

Answer 18

painless bleeding >24 weeks that is either unprovoked or coitus related, minor or major

Question 19

What signs will direct you to a diagnosis of PP?

Answer 19

soft, non-tender uterus with a high presenting part, have an increased tendency for malpresentations and CTG will be normal

Question 20

What investigation should not be done if suspecting a placenta praevia?

Answer 20

Vaginal examination

Question 21

How do you assess risk for pre-term delivery in placenta praevia?

Answer 21

cervical length at 34 weeks

Question 22

How should a stable mother with placenta praevia be managed?

Answer 22

Monitoring
corticosteroids from 34-36+6 weeks for lung maturation
MgSo4 for neuro protection
Delivery timing

Question 23

If pre-term but stable what should be done?

Answer 23

Tocolysis for 48hrs to allow administration of corticosteroids and MgSo4

Question 24

If mother is not stable what should be done?

Answer 24

Large bore cannulas, FBC, clotting, LFT, U&E, Kleihauers, administration of anti-D
may need to activate the major haemorrhage protocol

Question 25

What sort of delivery should be considered in placenta praevia?

Answer 25

C-section = if <2cm from internal os or the placenta covers os or malpresentation

Vaginal = if >2cm from os and no malpresentation

Question 26

What is placenta accreta?

Answer 26

This is when the placenta is abnormally adherent to the uterine wall

Question 27

What is placenta increta?

Answer 27

Adherent to the myometrium

Question 28

What is placent percreta?

Answer 28

Adherent to the bladder

Question 29

How is placenta accreta diagnosed?

Answer 29

MRI

Question 30

What increases risk of placenta accreta?

Answer 30

Multiple C-sections, placenta praevia

Question 31

What is the presentation of placenta accreta?

Answer 31

PPH (expect >3L blood loss) and can end up having a hysterectomy

Question 32

What is the management of placenta accreta?

Answer 32

stabilise the patient
activate major haemorrhage protocol
urgent CS + hysterectomy

Question 33

What is uterine rupture?

Answer 33

this is the full thickness tear of the uterus

Question 34

What are RF for uterine rupture?

Answer 34

Previous CS/uterine surgery, obstructed labour, IOL, multiparity

Question 35

What is the presentation of uterine rupture?

Answer 35

acute abdo, severe pain with guarding and shoulder tip pain, loss of contractions, foetal distress, maternal collapse, PV bleeding

Question 36

What is vasa praevia?

Answer 36

This is when the foetal vessels are below the presenting part and are close to the internal os - it is likely that thet will rupture on labour

Question 37

How is vasa praevia diagnosed?

Answer 37

at antenatal screening via TVUS or TAUS with doppler

Question 38

What should be done if vasa praevia is diagnosed?

Answer 38

steroids from 32 weeks, admit if risk of ROM, plan elective CS for 34-36 weeks.