Bleeding in Late Pregnancy Flashcards
What is antepartum haemorrhage?
Bleeding >24 weeks gestation to before the end of stage 2 labour
What is placental abruption?
This is when the normally implanted placenta becomes removed from the uterine wall (detaches) before or during the birth of the baby.
How does placental abruption occur?
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
What can placental abruption cause in the foetus?
Distress, hypoxia and IUD
What is a Couvelaire’s uterus?
When there is externsive bleeding into to myometrium resulting in haematoma formation
How will a placental abruption present?
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
What are the signs of placental abruption?
Large for dates, uterine tenderness, hard, woody uterus, PROM, foetal parts are difficult to identify
What will a CTG show in placental abruption?
irritable uterus (1 contraction/min) plus abnormal FHR (bradycardia or absent)
What should be done if FHR is not detected on CTG?
USS
Is USS a good way of diagnosing placental abruption?
No - it will miss 3/4
How do you manage a placental abruption?
Stabilise and resus the mother, urgent CS
How should you resus the mother in placental abruption?
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
How often will PPH and IUD occur in placental abruption?
PPH = 25% IUD = 14%
What is placenta praevia?
This is when the placenta covers the internal cervical os - LLP is when the placenta <2cm from the os
What are some risk factors for placenta praevia?
Previous placenta praevia, C-sections (increases with number), smoking, increased age, deficient endometrium, IVF
How will placenta praevia be detected?
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
When should an MRI be carried out?
If suspecting placenta accreta
How might placenta praevia present?
painless bleeding >24 weeks that is either unprovoked or coitus related, minor or major
What signs will direct you to a diagnosis of PP?
soft, non-tender uterus with a high presenting part, have an increased tendency for malpresentations and CTG will be normal
What investigation should not be done if suspecting a placenta praevia?
Vaginal examination
How do you assess risk for pre-term delivery in placenta praevia?
cervical length at 34 weeks
How should a stable mother with placenta praevia be managed?
Monitoring
corticosteroids from 34-36+6 weeks for lung maturation
MgSo4 for neuro protection
Delivery timing
If pre-term but stable what should be done?
Tocolysis for 48hrs to allow administration of corticosteroids and MgSo4
If mother is not stable what should be done?
Large bore cannulas, FBC, clotting, LFT, U&E, Kleihauers, administration of anti-D
may need to activate the major haemorrhage protocol
What sort of delivery should be considered in placenta praevia?
C-section = if <2cm from internal os or the placenta covers os or malpresentation
Vaginal = if >2cm from os and no malpresentation
What is placenta accreta?
This is when the placenta is abnormally adherent to the uterine wall
What is placenta increta?
Adherent to the myometrium
What is placent percreta?
Adherent to the bladder
How is placenta accreta diagnosed?
MRI
What increases risk of placenta accreta?
Multiple C-sections, placenta praevia
What is the presentation of placenta accreta?
PPH (expect >3L blood loss) and can end up having a hysterectomy
What is the management of placenta accreta?
stabilise the patient
activate major haemorrhage protocol
urgent CS + hysterectomy
What is uterine rupture?
this is the full thickness tear of the uterus
What are RF for uterine rupture?
Previous CS/uterine surgery, obstructed labour, IOL, multiparity
What is the presentation of uterine rupture?
acute abdo, severe pain with guarding and shoulder tip pain, loss of contractions, foetal distress, maternal collapse, PV bleeding
What is vasa praevia?
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
How is vasa praevia diagnosed?
at antenatal screening via TVUS or TAUS with doppler
What should be done if vasa praevia is diagnosed?
steroids from 32 weeks, admit if risk of ROM, plan elective CS for 34-36 weeks.
