Bleeding in Late Pregnancy Flashcards
What is considered as bleeding in LATE pregnancy?
- UK >24 wks
Define antepartum hemorrhage.
- bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
What placental problem causes APH?
- placenta praevia
- placental abruption
What are local causes of APH?
- Ectropion
- Polyp
- Infection
- Carcinoma
What uterine problem may cause aph?
- uterine rupture
Name another cause of APH; regarding the fetal blood vessels…
- Vasa praevia
What is the DDX of APH?
- heavy show
- cystitis
- hemorrhoids
What is heavy show?
- type of vaginal discharge containing mucus with bright red/ dark brown
- usually before labour !
What is considered as MASSIVE APH?
> 1000ml
and/or shock
WHat is considered as MINOR APH?
- <50ml
What is placental abruption?
- separation of a NORMALLY implanted placenta (partially/totally) BEFORE fetal birth
How common is placental abruption?
- only 1% of pregnancies
- —-but 40% of APH cases
Why does placental abruption occur?
- vasospasm followed by arteriole rupture in to the decidua (blood escapes into AMNIOTIC sac or further UNDER the placenta and into myometrium)
—cause tonic contraction and interrupts placental circulation; causing fetal hypoxia ==> COUVELAIRE uterus (concealed placental abruption)
What cause placental abruption?
- pre-eclampsia/HTN
- Trauma *blunt force—-domestic violence/MVA
- drug use
- polyhydramnios/ multiple preg./ preterm-PROM
- abnormal placenta
- previous abruption
- —–renal disease, thrombophilias/ DM
How does placental abruption present as?
- CONTINUOUS severe abdominal pain
- –labour is meant to be INTERMITTENT pain
- BACKACHE (if posterior placenta)
- Bleeding (may be concealed) > couvelaire uterus, dx on laparotomy
- preterm labour
- —maternal collapse
SIgns of placental abruption?
- unwell, distressed pt
- LFD/ normal
- uterine tenderness
- woody HARD uterus
- hard to identify fetal parts
- preterm labour (with heavy show)
- —fetal heart: Bradycardia/ absent (IUD)
- –CTG= irritable uterus (tachycardia/ loss of variability/ decelerations)
How to manage placental abruption?
- resuscitate mom
- Rapid assessment and delivery
- communicate (Neonatal team/ midwife/ obstretician/ anaesthetists)
- manage complications
- debrief parents
What investigations and actions are carried out for management of placental abruption?
- 2 large bore IV access, FBC, Clotting, LFT, U&Es, cross-matched 4-6 units red packed cells, Kleihauer
- IV fluids (care with Pre-eclampsia)
- catheterise! —hrly urine volumes
- CTG
- USS (fails to detect 3/4 cases of abruption)
How is a delivery usually performed with placental abruption?
- urgent C-SECTION
- ARM (Artificial rupture of membranes) and IOL
- expectant management (only for MINOR)
What is a couvelaire uterus?
- hematoma bruised uterus
- massive intravasation of blood into the uterine musculature (up till the uterine serosa)
What are maternal complications of placental abruptio?
- hypovolemic shock
- anemia
- PPH (25%)
- renal failure from renal tubular necrosis
- infection
- prolonged hospital stay > psych
- thromboembolism
- mortality is rare
- coagulopathy (FFP/ cryoprecipitate)
- —blood transfusion problems
Fetal complications from placental abruption
Fetal Death- Intrauterine death( 14%)
- hypoxia
- prematurity
- Small for gestational age and fetal growth restriction
How to prevent placental abruption?
- stop smoking
- Low-dose aspirin
- LDA and LMWH for anti-phospholipid $
What is placental praevia ?
- when placenta lies DIRECTLY over the internal os
- —-after 16wks the term of low-lying placenta should be used when the placental edge is LESS than 20 mmfrom the internal os —-seen on TVS `
What is the lower segment of the uterus? Why is it not the ideal spot for the placenta to be placed?
- part of the uterus BELOW the utero-vesical peritoneal pouch (superiorly) and internal os inferiorly
- the part of the uterus extending 7 cm from the top of the internal os
- thinner, less muscle fibres
- part of the uterus which does not contract in labour- just dilates
What % of APH is attributed to placenta Praevia?
- 20%
What is a huge risk factor for placenta praevia to develop?
- prior c-sections from previous pregnancy
What past uterine problems may result in placenta praevia?
- deficient endometrium due to hx of:
- uterine scar/ endometritis/ manual removal of placenta/ curettage/ submucous fibroid
What are other risk factors of placenta praevia apart from C-section?
Previous placenta praevia Smoking Assisted reproductive technology Previous termination of pregnancy Multiparity (>40 years) Multiple pregnancy
How and when to screen for placental praevia?
by TVS and Transabdominal scan
- mid-trimester fetal anomaly scan should include placental location!
- —if present RE-SCAN at 32 and 36 wks
—-assess cervical length before 34 wks for risk of Preterm labour
Why do a MRI scan after the screening for placental location?
- if placenta accreta is suspected
What are the symptoms of PP?
- painLESS bleeding >24wks
- coitus may trigger; otherwise unprovoked
- minor or severe bleeding
- pt’s condition proportional to amount bled
What are the signs of P.P?
- soft, non-tender uterus
- HIGH presenting part
- malpresentation (breech/transverse/oblique)
- normal CTG
Do you perform a Vaginal examination on a pt with placenta previa?
- DO NOT PERFORM VE until PP is EXCLUDED !!!
- —-speculum examination may be useful