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Reproduction > Bleeding in late pregnancy > Flashcards

Bleeding in late pregnancy Flashcards

1
Q

Define bleeding in late pregnancy

A

Bleeding >24 weeks (UK)

>20 weeks (USA)

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2
Q

Define antepartum hemorrhage (APH)

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

List the different aetiologies of APH

A
  1. Placental problem - praevia, abruption
  2. Uterine problem - rupture
  3. Vasa praevia
  4. Local causes - ectopion, polyp, infection, Ca
  5. Indeterminate
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4
Q

What are the differentials for APH

A

Heavy show
Cystitis
Haemorrhoids

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5
Q

What are the categories/quantities of APH?

A
  1. Spotting: staining, streaking, wiping
  2. Mild: <50ml, settled
  3. Moderate: 50-1000ml, no shock
  4. Severe: >1000ml and/or shock
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6
Q

What is placental abruption?

A

Partial or total separation of a NORMALLY implanted placenta before birth of the fetus

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7
Q

Placental abruption can be detected via US - T or F

A

F

CLINICAL DIAGNOSIS

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8
Q

What is the pathology of placental abruption?

A

Vasospasm followed by arteriole rupture into the decidua
Blood escapes into amniotic sac or further under placenta into myometrium
This causes tonic contraction of uterus and interrupts placental circulation which causes hypoxia
Result - couvelaire uterus

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9
Q

List the risk factors for placental abruption

A
  • unknown
  • pre-eclampsia/HTN
  • Trauma - blunt/forceful
  • Polyhydramnios, multiple pregnancy, pre labour rupture of membranes
  • Diabetes/Medical thrombophillias/renal diseases
  • Abnormal placenta
  • Previous abruption - recurrence 10%
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10
Q

What are the symptoms of placental abruption?

A 
Severe abdominal pain (continuous)
Backache (with posterior placenta)
Bleeding (may be concealed) 
Pre-term labour 
Maternal collapse (sometimes)
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11
Q

Signs of placental abruption

A

Patient appears unwell and distressed
Signs may be inconsistent with revealed blood
Uterus LFD or normal
Uterine tendernes
Uterus is woody hard
Foetal parts difficult to identify
May be in pre-term labour (with heavy show)
Foetal HR: bradycardia/absent (IUD)
CTG: irritable uterus (1 contraction/min) FH- tachycardia, deccels, loss of variability

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12
Q

Steps for managing placental abruption

A
  1. Resuscitate mother
  2. Assess & deliver baby
  3. Manage the complications
  4. Debrief the parents
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13
Q

What investigations are done during management of mother with placental abruption?

A

2 large bore IV access:

  • FBC
  • Clotting
  • LFT
  • U & E
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14
Q

What is administered to mother during management of her placental abruption?

A

Cross match 4-6 units red packed cells
Kleihauer test - detect transplacental hemorrhage
IV fluids (careful with pre-eclampsia)
Catheterise - hourly urine volumes

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15
Q

How to asses and deliver baby in placental abruption?

A

Assess foetal HR - CTG (uss if no foetal heart)

Delivery:

  • urgent by C-sec
  • ARM and induction of labour
  • Expectant/conservative management (only for minor, allow steroid cover)
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16
Q

Maternal complications of placental abruption

A 
Hypovolaemic shock
Anaemia
PPH (25% )
Renal failure  from renal tubular necrosis 
Coagulopathy ( FFP, cryoprecipitate)
Infection
Prolonged hospital stay Psychological sequelae 
Complications of blood transfusion
Thromboembolism
Mortality  rare
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17
Q

Foetal complications of placental abruption

A

Fetal Death- Intrauterine death( 14%)
hypoxia
prematurity
Small for gestational age and fetal growth restriction

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18
Q

How is placental abruption prevented?

A

Antiphospholipid syndrome: LMWH & LDA
Smoking cessation
LDA

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19
Q

Placenta praaevia vs low-lying placenta

A

Placenta praevia: placenta lies directly over internal os

Low-lying placenta: >16/40, placental edge is less than 20mm from internal os on TA or TVS

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20
Q

What are the anatomical, physiological and mechanical definitions of the lower segment of the uterus?

A

ANATOMICAL:

  • Part of the uterus below the utero-vesical peritoneal pouch superiorly and internal os inferiorly
  • thinner, less muscle and fibre than upper uterus

MECHANICAL:
- Part of the uterus 7cm from the level of internal os

PHYSIOLOGICAL:
- part of the uterus which does not contract in labour but passively dilates

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21
Q

Risk factors for placenta praevia

A 
Previous C-Sec **
Previous placenta praevia 
Previous termination of pregnancy
Smoking
Assisted reproductive technology and maternal smoking
Multiparity
>40 years
Multiple pregnancy
History of: uterine scar, endometriosis, fibroids, curettage, manual removal of placenta (these cause deficient endometrium)
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22
Q

When is placenta praevia screening carried out?

A

Mid-trimester foetal anomaly scan

Rescan at 32 and 36 weeks if persistent placenta praevia or LLP

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23
Q

Which type of scan is best to detect placenta praevia?

A

TVS> TA

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24
Q

How to asses risk of preterm labour in placenta praevia?

A

Asses cervical length before 34 weeks

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25
Q

Symptoms of placenta praevia

A

Painless bleeding > 24 weeks
Usually unprovoked but can be triggered by coitus
Bleeding can be minor
Patient’s condition proportional to amount of bleeding observed

26
Q

Signs of placenta praevia

A

Uterus:

  • soft, non tender
  • Presenting part high

Malpresentations:

  • breech
  • Trasnsverse
  • Oblique

CTG: NORMAL
DO NOT PERFORM VAGINAL EXAM UNTIL PLACENTA PRAEVIA RULED OUT

27
Q

How to diagnose placenta praevia

A

Check anomaly scan
Confirm by TV ultrasound
MRI to rule out accreta

28
Q

How to manage a non-bleeding placenta praevia

A

Advise patient to:

  • attend immediately if bleeding, spotting, contractions or pain
  • No sex

Antenatal corticosteroids b/w 34 to 35+6 weeks or < 34+0 weeks of gestation in women with increased risk of preterm delivery

MgSO4 - neuro-protection at 24-32 wks if planning delivery

Consider delivery at 34 to 36+6 wks if histroy of PV bleeding or other risks of preterm delivery

If uncomplicated placenta praevia, delivery b/w 36 and 37 weeks

29
Q

How to manage a bleeding placenta praevia

A

Admit and resuscitate (ABCDE)

  • MDT (obs, anaesthetist, neonatal team, theatre, haematologist)
  • 2 large bore IV access
  • FBC, cloting, LFT, U&E, Kleihauer (if rh -ve)
  • Cross match 4-6 units red packed cells
  • major hermorrhage protocol
  • IV fluids or transfuse
  • Anti D (if Rh neg)

Assess foetal wellbeing

  • Foetal HR - CTG after 28 weeks
  • Steroids (24 to 34+6 wks)
  • MGSO4 (if planning delivery)
  • Expectant/conservative management if stable
30
Q

When is C-sec indicated in delivery of placenta praevia?

A

If placenta covers os or <2cm from cervical os

Note:
Consent to include hysterectomy and risk of General Anaesthesia
Cell salvage
Skin and uterine incisions vertical <28weeks if transverse lie
Aim to avoid cutting through the placenta

31
Q

When is vaginal delivery indicated in placenta preavia?

A

If placenta >2cm from os and no malpresentation

32
Q

Define placenta accreta

A

Morbidly adherent placenta

33
Q

What are the major risk factors of placenta accreta?

A

Placenta praevia

Prior C-sec

34
Q

What is it called when placenta invades myometrium?

A

Increta

35
Q

What is it called when placenta invades uterus to bladder?

A

Percreta

36
Q

How to manage placenta accreta?

A 
Multidisciplinary management
Prophylctic internal iliac artery balloon 
Caesarean hysterectomy
Blood loss - >3L expected
Conservative management
37
Q

Define uterine rupture

A

Full thickness opening of uterus

38
Q

What are the risk factors of uterine rupture?

A

Previous C-sec/uterine surgery
Multiparity and use of prostaglandins/syntocinon
Obstructed labour

39
Q

Symptoms of uterine rupture

A

Severe abdominal pain
Shoulder-tip pain
Maternal collapse
PV bleeding

40
Q

Signs of uterine rupture

A 
Intrapartum - loss of contractions
Acute abdomen
Loss of contractions
Peritonism
Fetal distress/IUD
41
Q

Management of a uterine rupture

A

Urgent Resuscitation & Surgical management
Communication( Midwives, Obstetrics, Anaesthetists, Neonatal team, Theatre, Haematologist)
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)

42
Q

Define vasa praevia

A

Unprotected foetal vessels traverse the membranes below the presenting part over the internal cervical os

Will rupture during labour or at amniotomy

43
Q

How is Vasa praevia diagnosed?

A

USS - TA and TV with doppler

44
Q

What are the two types of Vasa Praevia?

A

Type I - vessel connected to a velamentous umbilical cord

Type II - when it connects the placenta with a succenturiate or accessory lobe

45
Q

Risk factors for Vasa praevia

A

Placental anomalies: bi-lobed or succenturiate lobes where the foetal vessels run through the membranes joining the separate lobes together
History of low lying placenta in 2nd trimester
Multiple pregnancy
IVF

46
Q

Management of Vasa Praevia for antenatal diagnosis

A

Steroids from 32 weeks
Consider inpatient management if risks of preterm birth (32-34 weeks)
Deliver by elective c/section before labour (34-36 weeks)

47
Q

Management of vasa praevia if diagnosed antenatally

A

Steroids from 32 weeks
Consider inpatient management if risks of preterm birth (32-34 weeks)
Deliver by elective c/section before labour (34-36 weeks)

48
Q

Management of vasa praevia if diagnosed during labour

A

Emergency caesarean delivery and neonatal resuscitation, including the use of blood transfusion if required

49
Q

Define post-partum hemorrhage

A

Blood loss equal to or exceeding 500ml after the birth of the baby

Primary within 24h of delivery
Secondary >24h - 6/52 post delivery

50
Q

What are the 2 classifications of PPH?

A

Minor: 500-1000ml (without clinical shock)

Major: >1000ml or signs of CV collapse or on-going bleeding

51
Q

List the causes of PPH

A

“4 T’s”

Tone
Trauma
Tissue
Thrombin

52
Q

Antenatal risk factors of PPH

A 
anaemia 
previous caesarean section
placenta praevia, percreta, accreta 
previous PPH
Previous retained placenta
Multiple pregnancy
Polyhydramnios
Obesity
Fetal macrosomia
( Caution with Jehovah’s Witness- Advanced Directive)
53
Q

Intrapartum risk factors for PPH

A

Prolonged labour
operative vaginal delivery
Caesarean section
Retained placenta

54
Q

How to prevent PPH?

A

Identify antenatal and intrapartum risk factors

Active management of 3rd stage: syntocinon/syntometrine IM/IV

55
Q

Initial management of pPH

A 
Call for help 
Simulatenous management: 
- Assess
- Stop the bleeding
- Fluid replacement
56
Q

Assess in PPH (step 1 of management)

A

Vital Signs: Pulse, BP, Capillary refill time, Saturations every 15min
Give Oxygen
Determine Cause of bleeding- 4Ts
Blood Samples: FBC, clotting, fibrinogen, U&E, LFT, Lactate
Cross-match 6 units red packed cells
May need Major Haemorrhage protocol

57
Q

How to stop thebleeding when managing PPH (step 2) .

A 
Uterine massage- bimanual compression
Expel clots 
5 units IV Syntocinon stat 40 units 
Syntocinon in 500ml Hartmann's - 125 ml/h
Foleys Catheter
Most cases respond
Confirm placenta and membranes complete
 Urinary Catheter 
500 micrograms Ergometrine IV (Avoid if Cardiac Disease / Hypertension) 
? Vaginal / perineal trauma - ensure prompt repair
 ? cervical trauma
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
58
Q

Non surgical techniques to stop bleeding in PPH

A

Packs & Balloons – Rusch Balloon, Bakri Balloon
Tissue Sealants
Interventional Radiology : Arterial Embolisation

59
Q

Surgical techniques to stop bleeding in PPH

A 
Undersuturing 
Brace Sutures – B-Lynch Suture
Uterine Artery Ligation 
Internal Iliac Artery Ligation 
Hysterectomy
60
Q

Fluid replacement in PPH (Step 3)

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

61
Q

Post delivery management of PPH

A

Thromboprophylaxis
De-brief couple
Manage anaemia (IV Iron/oral)
Datix and risk management

Reproduction (32 decks)

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