Bleeding in Late Pregnancy Flashcards
what bleeding counts as early pregnancy
<24 weeks
what bleeding is late pregnancy
> 24 weeks
bc this is when the baby is viable
what is antepartum haemorrhage
bleeding from the genital tract after 24 weeks gestation and before the second stage of labour
causes of antepartum haemorrhage
placental problems (praaevia, abruption)
Uterine problems (rupture)
Local causes (ectropion, polyp. infection, carcinoma)
Vasa praaevia
Unknown
what are some differentials for antepartum haemorrhage
heavy show
cystitis
haemorrhoids
what is a minor APH
<50ml settled
what is a major APH
50-1000ml
no shock
what is a massive APH
> 1000ml and/or shock
what is placental abruption
premature breaking away of a normal placenta from the uterus partially or totally before birth
is a CLINICAL diagnosis - no investigations done
cause placental abruption
vasospasm then arteriole rupture into the decider
blood escapes into the amniotic sac or further under the placenta into myometrium
causes myometrium contraction and interrupts placental circulation causing hypoxia
what is couvelaire uterus
placental abruption causes bleeding that penetrates the myometrium and goes into the peritoneal cavity
medical emergency
risk factors for placental abruption
unknown pre-eclampsia/hypertension trauma smoking/cocaine/amphetamine thrombiphilias/ renal disease/ diabetes polyhydraminos multiple pregnancy preterm baby abnormal placenta previous abruption
symptoms of placental abruption
continuous severe abdominal pain backache with posterior placenta bleeding preterm labour maternal collapse
signs of placental abruption
unwell distressed patient Large for dates or normal uterus uterine tenderness woody hard uterus fetal parts difficult to identify may be in preterm labour
fetal Bradycardia/absent HR
CTG shows irritable uterus
management of placental abruption
resuscitate mother
assess and deliver the baby (urgent CS or IOL)
manage the complications
debrief parents
how do you resuscitate the mother in placental abruption
2 large bore IV access
bloods: FBC, clotting, LFT U&Es, cross match, kleihauer (RH-)
IV fluids
catheterise
complications of placental abruption
Hypovolaemic shock Anaemia PPH Renal failure from renal tubular necrosis Coagulopathy infection complications of blood transfusion thromboembolism prolonged hospital stay psychological sequelae fetal heath fetal hypoxia prematurity small for gestational age, FGR
what is placenta praevia
placenta is low lying directly over the internal os
what is a low lying placenta
at 16/40 weeks when the placenta is less than 20 mm from the internal os on trans abdominal or transvaginal scanning
risk factors for placenta praaevia
previous CS previous TOP advanced maternal age multiparty multiple pregnancy
when is placenta praaevia screened for
mid trimester fetal anomaly scan includes placental localisation
rescan at 32 and 36 weeks is persistent placenta praevia or low lying placenta
symptoms of placenta praaevia
Painless bleeding >24 weeks
can be triggered by sex but usually unprovoked
fetal movements present
signs of placenta praaevia
uterus soft and non tender
presenting part high
malpresentation (breech, transverse, oblique)
normal CTG
do not perform a digital vaginal exam until excluded PP (speculum examination instead)
how do you diagnose placental praaevia
Check anomaly scan
Confirm with transvaginal US
MRI to exclude placenta accrete (placenta invades into the myometrium)
how do you manage placenta praevia
Resuscitate mother (ABCDE) Asses baby's condition Investigations Steroids Anti D if Rh- Conservative management if stable Steroids between 24 and 35+6 weeks delivery plan at/near term
how do you manage a placenta praevia which isn’t bleeding
advise patient to attend immediately if any bleeding - including spotting
contractions or pain
advice no sexual intercourse
how do you manage a significant bleed from placenta praevia
Admit and resuscitate
2 large bore IV access
FBC, clotting, LFTs, U+Es, kleihauer, cross match
major haemorrhage protocol
IV fluids or blood transfusion
Anti D if RH -
asses fetal well being, monitor fetal heart, give steroids and magnesium sulphate (24-32 weeks if planning delivery)
expectant management if stable
expedite delivery if active bleeding
how do you delivery the baby in placenta praevia
C/Section if placenta covers os or <2cm from cervical os
Vaginal if placenta is >2cm from os and no malpresentation
what is placenta accreta
morbidly adherent placenta (placenta starts to invade the uterine wall)
what is placenta increta
when the placenta invades the myometrium
what is placenta percreta
when the placenta penetrates the uterus through to the bladder
how do you manage placenta accreta
prophylactic internal iliac artery balloon
caesarian hysterectomy
blood loss >3L expected
conservative management
what is a uterine rupture
full thickness opening of uterus
including the serosa
if the serosa is intact it is called uterine dehiscence
what are some risk factors for uterine rupture
previous C/Section or uterine surgery
multiparty and use of prostaglandins (eg. syniocin in IOL)
obstructed labour
symptoms of uterine rupture
severe abdominal pain
shoulder-tip pain
maternal collapse PV bleeding
signs of uterine rupture
Intra-partum loss of contractions
Acute abdomen
peritonism
fetal distress/ IU death
management of uterine rupture
urgent resuscitation and surgical management
2 large bore IV access
FBC, clotting, LFT, U+Es, Kleihauer
cross match
major haemorrhage protocol
IV fluids/blood transfusion
Anti D
send to theatre
what is vasa praevia
unprotected free fetal vessels transverse the membranes below the presenting part of the internal cervical os
will rupture during labour or amniotomy
How do you diagnose vasa praevia
ultrasound (trans abdominal and transvaginal with doppler)
risk factors for vasa praevia
placental anomalies
low lying placenta
multiple pregnancy
IVF
how do you manage vasa praevia
antenatal diagnosis
steroids from 32 weeks
delivery by elective CS before labour
if there’s an antepartum haemorrhage from vasa praevia - emergency c section
what are some other causes of bleeding in late pregnancy
ectropion polyp carcinoma vaginal causes unexplained
what is a post part haemorrhage
blood loss >500ml after the brith of the baby
primary - within 24 hours
secondary - >24 hours
what is a minor PPH
500ml-1000ml without clinical shock
what is a major PPH
> 1000ml or signs of shock or ongoing bleeding
4Ts - causes of post partum haemorrhage
Tone (uterine atony)
Trauma
Tissue (retained placental/membrane tissue)
Thrombin (bleeding disorders)
risk factors for PPH
anaemia previous CS Placental praevia, percreta, accreta previous PPH previous retained placenta multiple pregnancy Polyhydramnios obesity fetal Macrosomia
how do you prevent PPH
Active management of third stage
syntocinon/syntometrine IM/IV
management of PPH
Asses
Stop bleeding
Fluid replacement
how do you stop the bleeding in PPH
Uterine passage - bimanual compression Expel clots 5 units IV syntocinin urinary catheter ergometrine IV prompt repair of trauma Carboprost/haemabate Misoprostol Tranexemic acid
examination under anaesthetic in theatre if persistent bleeding
what is done in theatre to stop PPH
packs and balloons
tissue sealants
interventional radiology
undersuturing brace sutures uterine artery ligation internal iliac artery ligation hysterectomy
management for a secondary PPH (>24hr - 6 weeks postnatally)
exclude retained products of conception with US
often caused by infection
how do you manage PPH post delivery
thrombophylaxis
debrief couple
manage anaemia
