Bleeding in Late Pregnancy

Question 1

bleeding in early vs late pregnancy?

Answer 1

early = <24 weeks
late = >24 weeks (antepartum haemorrhage)

Question 2

functions of the placenta?

Answer 2

sole source of nutrition for foetus from 6 weeks
gas transfer
metabolism/waste production
hormone production (HPL etc)
protective filter
very vascular

Question 3

what is APH?

Answer 3

antepartum haemorrhage
bleeding from the genital tract after 24 weeks gestation and before the end of the 2nd stage of labour
bleeding from or into the genital tract occurring from 24 weeks of pregnancy and prior to the birth of the baby

Question 4

what can cause APH?

Answer 4

placental problem - praevia or abruption
uterine problem - rupture
local causes - ectropion, polyp, infection, carcinoma
vasa praevia
indeterminate

Question 5

APH differentials?

Answer 5

heavy show
cystitis
haemorrhoids

Question 6

quantification of APH?

Answer 6

spoting = staining/streaking of underwear, seen on wiping
minor = <50ml, settled
major = 50-1000ml, no shock
massive = >1000ml and/or shock

Question 7

what is placental abruption?

Answer 7

separation of a normally implanted placenta (partially or totally) before birth of foetus

Question 8

how is placental abruption diagnosed?

Answer 8

clinical diagnosis

Question 9

pathology in placental abruption?

Answer 9

vasospasm followed by arteriole rupture into the decidua

blood escapes into the amniotic sac or further under the placenta and into myometrium

Question 10

what does abruption cause?

Answer 10

causes tonic contraction and interrupts placental circulation which causes hypoxia
results in couvelaire iterus

Question 11

risk factors for abruption?

Answer 11

unknwon 
pre-eclampsia/hypertension
trauma
smoking/cocaine/amphetamines
medical thrombophilia/renal disease/diabetes
polyhydramnios
multiple pregnancy
preterm/prelabour rupture of membranes
abnormal placenta (sick placenta)
previous abruption

Question 12

symptoms of abruption?

Answer 12

severe continuous abdo pain 
backache with posterior placenta
bleeding (may be concealed)
pre-term labour
may present with maternal collapse

Question 13

signs of abruption?

Answer 13

unwell distressed patient
bleeding
uterus large for dates or normal
uterine tenderness
woody hard uterus
foetal parts hard to identify
may be in pre-term labour
bradycardia/absent foetal heart beat
CTG shows irritable uterus (1 contraction per min, tachycardia)

Question 14

how is abruption managed?

Answer 14

resuscitate mother
asses and deliver baby
IV fluids (take care with pre-eclampsia)
catheterise - hourly urine volumes
manage complications
debrief the parents

Question 15

what is done for mother in abruption?

Answer 15

2 large bore IV access
FBC
clotting
LFT and U&Es
cross match 4-6 units red packed cells
kleihauer
IV fluids (take care with pre-eclampsia)
catheterise - hourly urine volumes

Question 16

how is foetus assessed?

Answer 16

assess fetal heart (CTG, US if no heart beat detected)

US generally doesnt detect abruption

Question 17

how is foetus delivered in abruption?

Answer 17

urgent delivery by C section (crash delivery?)
ARM and induction of labour
expectant/conservative management (only if minor and should allow steroid cover)

Question 18

maternal complications of abruption?

Answer 18

hypovolaemic shock
anaemia
PPH (mainly)
renal failure from tubular necrosis
coagulopathy
infection
prolonged hospital stay and psychological sequele
complications of blood transfusion
thromboembolism
mortality is rare

Question 19

foetal complications of abruption?

Answer 19

fetal death (IUD)
hypoxia
prematurity
small for gestational age and fetal growth restriction

Question 20

how can abruption be prevented?

Answer 20

manage any antiphospholipid syndrome
smoking cessation
low dose aspirin

Question 21

what is placenta praevia vs low lying placenta?

Answer 21

placenta praevia = when the placenta lies directly over the internal os
low lying placenta = term used after 16 weeks when the placental edge is less than 20mm from the internal os on transabdominal/transvaginal scanning

Question 22

anatomical lower segment of the uterus?

Answer 22

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

Question 23

physiological lower segment of the uterus?

Answer 23

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

Question 24

metric lower segment of the uterus?

Answer 24

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

Question 25

what increases risk of placenta praevia?

Answer 25

C section in previous pregnancies
previous placenta praevia
smoking
assisted reproduction
previous abortion
multiparity
advanced age >40
multiple pregnancy
deficient endometrium

Question 26

what screening is done for placenta praevia?

Answer 26

mid-trimester fetal anomaly scan including placental localisation
- rescan at 32 and 36 weeks if praevia present
transvaginal scan
assess cervical length (before 34 weeks) for risk of pre-term labour
MRI if placenta accreta suspected

Question 27

symptoms of placenta praevia?

Answer 27

painless bleeding >24 weeks
usually unprovoked but coitus can trigger bleeding
bleeding can be minor (spotting) or severe

Question 28

how is severity of placenta praevia relates to volume of bleeding?

Answer 28

directly proportional to amount of observed bleeding

Question 29

signs of placenta praevia?

Answer 29

soft, non-tender uterus
high presenting part
malpresentation (breech etc)
CTG usually normal

Question 30

important to exclude placentae praevia before doing what?

Answer 30

vaginal examination

- speculum examination may be useful

Question 31

how is placenta praevia diagnosed?

Answer 31

CHECK ANOMALY SCAN
confirm via TV US scan
MRI for excluding placenta accrete
digital vaginal examination

Question 32

how is placentae praevia managed?

Answer 32

resuscitate mother (ABCDE)
assess baby
investigations
conservative management if stable
admit if PV bleeding, distant from hospital, transport problems of if a Jehovah's Witness (do VTE score for JWs) and keep in for 24 hrs intil bleeding has stopped
prevent and treat anaemia
make delivery plan

Question 33

when should a patient with suspected placenta praevia be advised to attend immediately?

Answer 33

bleeding, including spotting, contractions or pain without sex

Question 34

how is placenta praevia without bleeding managed?

Answer 34

antenatal corticosteroids between 24 and 35 weeks or <34 weeks gestation in women at higher risk of preterm birth
consider tocolysis if symptomatic placenta praevia or a low lying placenta for 48 hrs