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REPRO > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

What is considered as bleeding in LATE pregnancy?

A
  • UK >24 wks
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2
Q

Define antepartum hemorrhage.

A
  • bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
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3
Q

What placental problem causes APH?

A
  • placenta praevia

- placental abruption

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4
Q

What are local causes of APH?

A
  • Ectropion
  • Polyp
  • Infection
  • Carcinoma
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5
Q

What uterine problem may cause aph?

A
  • uterine rupture
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6
Q

Name another cause of APH; regarding the fetal blood vessels…

A
  • Vasa praevia
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7
Q

What is the DDX of APH?

A
  • heavy show
  • cystitis
  • hemorrhoids
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8
Q

What is heavy show?

A
  • type of vaginal discharge containing mucus with bright red/ dark brown
  • usually before labour !
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9
Q

What is considered as MASSIVE APH?

A

> 1000ml

and/or shock

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10
Q

WHat is considered as MINOR APH?

A
  • <50ml
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11
Q

What is placental abruption?

A
  • separation of a NORMALLY implanted placenta (partially/totally) BEFORE fetal birth
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12
Q

How common is placental abruption?

A
  • only 1% of pregnancies

- —-but 40% of APH cases

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13
Q

Why does placental abruption occur?

A
  • 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)

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14
Q

What cause placental abruption?

A
  • pre-eclampsia/HTN
  • Trauma *blunt force—-domestic violence/MVA
  • drug use
  • polyhydramnios/ multiple preg./ preterm-PROM
  • abnormal placenta
  • previous abruption
  • —–renal disease, thrombophilias/ DM
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15
Q

How does placental abruption present as?

A
  • 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
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16
Q

SIgns of placental abruption?

A
  • 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)
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17
Q

How to manage placental abruption?

A
  • resuscitate mom
  • Rapid assessment and delivery
  • communicate (Neonatal team/ midwife/ obstretician/ anaesthetists)
  • manage complications
  • debrief parents
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18
Q

What investigations and actions are carried out for management of placental abruption?

A
  • 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)
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19
Q

How is a delivery usually performed with placental abruption?

A
  • urgent C-SECTION
  • ARM (Artificial rupture of membranes) and IOL
  • expectant management (only for MINOR)
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20
Q

What is a couvelaire uterus?

A
  • hematoma bruised uterus

- massive intravasation of blood into the uterine musculature (up till the uterine serosa)

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21
Q

What are maternal complications of placental abruptio?

A
  • 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
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22
Q

Fetal complications from placental abruption

A

Fetal Death- Intrauterine death( 14%)

  • hypoxia
  • prematurity
  • Small for gestational age and fetal growth restriction
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23
Q

How to prevent placental abruption?

A
  • stop smoking
  • Low-dose aspirin
  • LDA and LMWH for anti-phospholipid $
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24
Q

What is placental praevia ?

A
  • 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 `
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25
Q

What is the lower segment of the uterus? Why is it not the ideal spot for the placenta to be placed?

A
  • 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
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26
Q

What % of APH is attributed to placenta Praevia?

A
  • 20%
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27
Q

What is a huge risk factor for placenta praevia to develop?

A
  • prior c-sections from previous pregnancy
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28
Q

What past uterine problems may result in placenta praevia?

A
  • deficient endometrium due to hx of:

- uterine scar/ endometritis/ manual removal of placenta/ curettage/ submucous fibroid

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29
Q

What are other risk factors of placenta praevia apart from C-section?

A 
Previous placenta praevia
Smoking
Assisted reproductive technology 
Previous termination of pregnancy 
Multiparity 
 (>40 years)
Multiple pregnancy
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30
Q

How and when to screen for placental praevia?

A

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

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31
Q

Why do a MRI scan after the screening for placental location?

A
  • if placenta accreta is suspected
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32
Q

What are the symptoms of PP?

A
  • painLESS bleeding >24wks
  • coitus may trigger; otherwise unprovoked
  • minor or severe bleeding
  • pt’s condition proportional to amount bled
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33
Q

What are the signs of P.P?

A
  • soft, non-tender uterus
  • HIGH presenting part
  • malpresentation (breech/transverse/oblique)
  • normal CTG
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34
Q

Do you perform a Vaginal examination on a pt with placenta previa?

A
  • DO NOT PERFORM VE until PP is EXCLUDED !!!

- —-speculum examination may be useful

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35
Q

How to confirm dx of P.P?

A
  • Anomaly scan (mid-trimester)
  • confirm by TV USG
  • MRI to exclude placenta accreta
36
Q

How to manage P.P?

A
  • ABC on mom
  • Assess bby
  • Investig.
  • conservative management; if stable
  • prevent and rx anemia
  • delivery plan near term
37
Q

When to admit a PP pt?

A
  • if PV bleeding
  • distant from hospital/ transport problems
  • jenovah’s witness ( do VTE score)
38
Q

If a P.P mom has been having PV bleeding; when is it recommended for delivery?

A

34wks-36 wks+6

—same if any other risk factors are present for PRE-TERM delivery

39
Q

If uncomplicated p.p when is best for delivery?

40
Q

How management procedures are done for P.P pt with bleeding hx?

A
  • admit and resuscitate
  • communicate
  • 2 Large bore IV access,
  • FBC, clotting , LFT, U& E , Kleihauer ( if Rh Neg)
  • Cross match 4-6 units Red packed cells
  • May need Major Haemorrhage protocol
  • IV fluids or transfuse
  • Anti D ( if Rh Neg)
41
Q

What is done for fetal management in a pp pt with bleeding hx?

A
  • MONITOR fetal well being (CTG after 28 weeks)
  • STEROIDs (24-34+6 weeks)
  • MgSO4 (neuroprotection 24-32wks) —-if planning delivery
  • conservative management if stable
42
Q

When do you advise a P.P pt to attend the ANC immediately?

A
  • if bleeding, spotting, contrxns or pain (even vague supra-pubic period like aches)
  • with no penetrative sex..?
43
Q

When is tocolysis given to P.P pt?

A
  • if symptomatic P.P or low-lying placenta

- for 48hrs for antenatal corticosteroids

44
Q

How does the location and presentation of the placenta, in Placenta previa, change the manner in which the baby is delivered?

A
  • C-section (if placenta covers OS or <2cm from os)

- Vaginal delivery (if >2cm from os and NO malpresentation)

45
Q

What actions should the senior operator and anesthetists gain consent for?

A
  • CONSENT to include hysterectomy AND RISK general anesthesia
46
Q

How are the surgical incisions diff. with transverse lie?

A
  • skin and uterine incisions done VERTICALLY

- —AVOID cutting placenta

47
Q

Define placenta accreta.

Seen in which other placental abnormality?

A
  • morbidly ADHERENT placenta

5-10% of Placenta Praevia

48
Q

What is placenta accreta a.w?

A
  • severe bleeding
  • PPH
  • considerable maternal morbidity
49
Q

MAjor risk factors of P.A?

A
  • placenta previa

- prior C-section

50
Q

What is P.Accreta?

A
  • invading myometrium : INCRETA

- penetrating uterus to bladder= Percreta

51
Q

What is done to manage P.A?

A
  • Prophylactic internal iliac artery balloon
  • Caesarean hysterectomy
  • Blood loss >3Litres expected
  • Conservative Management (?plus Methotrexate)
52
Q

What is uterine rupture?

A
  • the full thickness of the uterus opens up
53
Q

Risk factors of uterine rupture?

A
  • previous C-section (1 IN 500)
  • previous uterine surgery
  • multiparity
  • IOL: w/ use of prostaglandins/syntocinon (1 IN 250) increases risk
  • obstructed labour
54
Q

Symptoms of uterine rupture?

A

Severe abdominal pain
Shoulder-tip pain
Maternal collapse
PV bleeding

55
Q

What are the signs of Uterine rupture? -

A 
Intra-partum - loss of contractions 
Acute abdomen
Presenting Part rises
Loss of uterine contractions
Peritonism
 Fetal distress / Intrauterine death
56
Q

How to manage uterine rupture?

A
  • RESUSCITATION and surgical management.
  • comms
  • 2 Large bore IV access,
    FBC, clotting , LFT, U& E , Kleihauer ( if Rh Neg)
    Cross match 4-6 units Red packed cells
    May need Major Haemorrhage protocol
    IV fluids or transfuse
    Anti D ( if Rh Neg)
57
Q

What is Vasa Previa?

A
  • unprotected fetal vessels traverse the membranes BELOW the presenting part over the internal cervical os
    > may rupture during labor or amniotomy
58
Q

How to dx Vasa Praevia?

A
  • Ultrasound transabdominal

- TVS with doppler

59
Q

What occurs if you were to Artificially rupture the membrane of a vasa praevia mother?

A
  • sudden dark red bleeding
  • fetal bradycardia and death
  • —-mortality is 60%
60
Q

What are the diff. types of Vasa Praevia?

A

Type 1: vessel is connected to a velamentous umbilical cord

2: vessel connects the placenta with an accessory lobe

61
Q

Risk factors of V.Previa?

A
  • bilobed placenta; fetal vessels run through the membranes; joining the seprate lobes together
  • hx of low-lying placenta in 2nd trimester
  • multiple preg
  • IVF (1 in 300)
62
Q

How to manage V.PREVIA?

A
  • Antenatal dx
  • steroids from 32 weeks
  • inpatient management if risk of pre-term (32-34wks)
  • –deliver by elective c-section before labour
  • placenta for histology
63
Q

What course of action if ruptured Vasa praevia was dx during labour?

A
  • emergency C-section
  • neonatal resuscitation
  • use of blood transfusion if needed
64
Q

Name other causes of APH.

A
  • cervical: Ectropion/ polyp/carcinoma
  • vaginal causes
  • unexplained
65
Q

Why is it significant to know if a pt is a Jenovah’s Witness?

A
  • they don’t accept any blood transfusions
66
Q

What is post-partum hemorrhage?

A

-blood loss equal to >500ml AFTER delivery of bby

67
Q

What is the diff. between Primary and secondary PPH?

A

Iary: within 24hr of delivery

IIary: >24hr- 6 wks post partum

68
Q

When is considered to be MAJOR PPH?

A
  • > 1000ml is lost

- signs of CVS collpase/ on going bleeding

69
Q

How to calculate blood volume in pregnancy?

A
  • 100 ml/ kg
70
Q

What are the 4 Ts in the causes of PPH?

A

Tone 70%
Trauma 20%
Tissue 10%
Thrombin <1%

71
Q

PPH risk factors…

A 
anaemia 
previous caesarean section
placenta praevia, percreta, accreta 
 previous PPH
Previous retained placenta
Multiple pregnancy
Polyhydramnios
Obesity
Fetal macrosomia
72
Q

How to prevent PPH?

A
  • identify Intra-partum risk factors: PROLONGED labour/ operative vaginal delivery/ C-section/ retained placenta
  • –actively manage third stage !!!—-Syncotonin/syntometrine (IM/IV)
73
Q

Initial management of PPH?

A
  • call for help

- SIMULTANEOUS management is key: ASSESS/ STOP bleeding/ FLUID replacement

74
Q

Management of Minor PPH….

A

IV access (one 14-gauge cannula)
Group & Save, FBC,coagulation screen, including fibrinogen
Observations: pulse, respiratory rate and blood pressure recording every 15 minutes
IV warmed crystalloid infusion

75
Q

What is the 1st line of action in stopping the bleeding; most cases respond to?

A
  • uterine massage (bimanual compression)
  • expel clots
  • 5 units IV Syntocinon stat 40 units
  • Syntocinon in 500ml Hartmann’s - 125 ml/h
  • Foleys C`atheter
76
Q

What is hartmann’s solution?

A

sodium lactate

77
Q

Another course of action to stop PPH?

A
  • confirm placenta and membranes complete
  • urinary catheter
  • 500 micrograms Ergometrine IV (Avoid if Cardiac Disease / Hypertension)
  • —prompt repair of vaginal/ perineal trauma
78
Q

What other meds can be given to stop the bleeding?

A 
Carboprost /Haemabate ( PGF2α) 250mcg IM every 15min ( Max 8 doses)
Misoprostol 800mcg PR
Tranexamic acid 0.5g-1g IV
EUA in theatre if persistent bleeding
CALL CONSULTANT
79
Q

Once in the OT room for examination under anaesthesia. What is she checked for?

A
  • Vaginal/cervical trauma
  • retained prods of conception
  • rupture
  • inversion allows advance techn.
80
Q

Surgical methods to stop bleeding?

A 
Undersuturing 
Brace Sutures – B-Lynch Suture
Uterine Artery Ligation 
Internal Iliac Artery Ligation 
Hysterectomy
81
Q

Non-surgical methods to stop bleeding?

A
  • Packs & Balloons – Rusch Balloon, Bakri Balloon
  • Tissue Sealants
  • Interventional Radiology : Arterial Embolisation
82
Q

How to replace fluid in PPH?

A

2 Large bore IV access
Rapid fluid resuscitation- Crystalloid Hartmann’s , 0.9% N/Saline
- Blood Transfusion early
- Consider O Neg if life threatening haemorrhage
- If DIC/coagulopathy – FFP, Cryoprecipitate, platelets
- Use Blood warmer
- Cell saver

83
Q

Management of Secondary PPH?

A
  • exclude retained products of conception with USS

- —infection likely to play role

84
Q

WHat occur post-delivery?

A

Thromboprophylaxis
Debrief couple
Manage anaemia – IV Iron/ oral
Datix & Risk Management

85
Q

Main 3 managment methods with APH?

A
  • Kleihauer, Anti-D, Steroids!

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