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Repro and Sexual Health > Bleeding in Late Pregnancy # > Flashcards

Bleeding in Late Pregnancy # Flashcards

1
Q

What defined bleeding in late pregnancy?

A

> 24 weeks

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2
Q

What are good questions to ask about bleeding in pregnancy?

A 
Amount
Colour
Is pain continuous or intermittent
MEWS score 
Any trigger; esp coital 
Foetal movements
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3
Q

What direct cause of pregnancies causes the most deaths in the 6 weeks postpartum?

A

VTE

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4
Q

When does the placenta form, and when is it fully functional?

A

Forms 6 weeks

Functional at 12 weeks

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5
Q

What are the functions of the placenta?

A

Gas transfer
Metabolism/ wast disposal
Hormone production (hPL)
Protective “filter”

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6
Q

What is the definition of APH?

A

Bleeding from genital tract after 24 weeks gestation and before the end of the 2nd stage of labour

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7
Q

What are the commonest causes of APH?

A

Abruption

Previa

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8
Q

What can cause APH?

A 
Placenta issues; praevia, abruption 
Uterine problem; rupture 
Indeterminate
Vasa praevia
Local; ectropion, polyp, infection, carcinoma
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9
Q

DDx of APH?

A

Heavy show
Cystitis
Haemorrhoids

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10
Q

What is the “show”?

A

Mucus plug comes away indicating start of labour

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11
Q

How can APH be quantified?

A

Spotting; staining, streaking, wiping
Minor; <50ml
Major; 50-1000ml
Massive; >1000ml and/or shock

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12
Q

What is a placental abruption?

A

Premature separation of a normally implanted placenta partially or totally before the birth of the foetus

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13
Q

Is an abruption a clinical or investigative diagnosis?

A

Clinical

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14
Q

How many pregnancies will an abruption complicate and what percentage of APH is due to ab abruption?

A

1% of pregnancies

40% of APH

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15
Q

What is the pathology of an abruption?

A

Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into the myometrium

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16
Q

Why is an abruption painful?

A

Results in tonic contraction and interrupts placental circulation which results in hypoxia

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17
Q

What is a couvelaire uterus?

A

Blue appearance to uterus due to bruising

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18
Q

Risk factors for development of a placental abruption?

A 
pre-eclampsia and maternal hypertension
previous placental abruption 
prolonged rupture of membranes
maternal age: pregnant women who are younger than 20 years or older than 35 years are at greater risk
maternal trauma
cigarette smoking
cocaine or other amphetamine use
thrombophilia
chorioamnionitis
short umbilical cord
multiparity
multifetal pregnancies
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19
Q

What are the symptoms of a placental abruption?

A 
Severe abdo pain; CONTINUOUS 
Backache with posterior placenta
Bleeding (may be concealed if retroplacental) 
Preterm labour
Maternal collapse
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20
Q

Signs of a placental abruption on examination?

A

Uterus large for dates or normal
Uterine tenderness
Woody hard uterus
Can be in preterm labour with heavy show

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21
Q

What condition will the foetus be in in placental abruption?

A

Foetal heart; bradycardia/ absent (IUD)

CTG; irritable uterus (1 contraction per min, FH abnormality, tachycardia, loss of variability, decelerations)

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22
Q

Basic management of a placental abruption?

A

Resuscitate mother
Assess and deliver baby
Manage complications
Debrief the parents

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23
Q

How should the mother be resuscitated in a placental abruption?

A 
2 large bore IVs
Bloods; FBC, clotting, LFT, U+Es, XM
4-6 units packed red cells
Kleihauer 
IV fluids (careful with PET) 
Catheterise
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24
Q

How should delivery be managed in a placental abruption?

A

Urgent delivery by c/s
ARM and induction of labour
Expectant/ conservative management (only for minor; allow steroid cover)

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25
Q

What are the maternal complications of a placental abruption?

A 
Hypovolaemic shock
Anaemia
PPH 
Renal failure from renal tubular necrosis
Coagulopathy (FFP, cryoprecipitate) 
Infection 
Prolonged hospital stay
Psychological sequelae; PTSD
Complications of blood transfusion 
Thromboembolism
Mortality rate
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26
Q

Foetal complications of placental abruption?

A

Foetal death; IUD
Hypoxia
Prematurity; iatrogenic or spontaneous
SGA and FGR

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27
Q

Can abruptions be prevented in future pregnancies?

A 
Recurrence is 10% 
APS; LMWH and LDA
Drug misuse; referral to drug misuse agencies
Smoking cessation 
Folic acid 
Domestic violence
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28
Q

What is a placenta praevia?

A

Placental lies directly over internal os

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29
Q

When should the term low lying placenta be used in place of placenta praevia?

A

After 16-40, low lying placenta should be used when the placental edge is less than 20 mm from the internal os on transabdominal or transvaginal scanning (TVS)

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30
Q

Anatomically, what is the lower segment of the uterus?

A

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

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31
Q

Physiologically, what is the lower segment of the uterus?

A

Part of uterus which does not contract in labour but passively dilates

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32
Q

Metrically, what is the lower segment of the uterus?

A

Part of uterus which is about 7cm from the level of the internal os

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33
Q

What percentage of APH is due to praevia?

A

20%

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34
Q

What is a big RF for placenta praevia?

A

C/s - increased risk in future pregnancies

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35
Q

What are the risk factors for placenta praevia?

A 
Previous c/s 
Previous praevia
Smoking 
ART 
Previous termination 
Multiparity
Maternal age >40 
Multiple pregnancy 
Deficient endometrium due to presence or history of; uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid
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36
Q

When is placenta praevia screened for?

A

20 week; midtrimester foetal anomaly scan should include placental localisation

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37
Q

When will you be rescanned if praevia is identified at the 20 week scan?

A

Rescan at 32 and 36 weeks if persistent praevia or LLP
TVUSS superior to transabdominal
Assess cervical length before 34 weeks for risk of preterm labour

38
Q

What should be performed if placenta accreta is suspected?

A

MRI

39
Q

What are the symptoms of placenta praevia?

A

Painless bleeding >24 weeks
Usually unprovoked by coitus can trigger
Bleeding can be minor or severe

40
Q

What are the signs of placenta praevia on examination?

A

Uterus soft and non-tender
Presenting part is high
Malpresentations - breech/ transverse/ oblique
Foetal heart; CTG normal

41
Q

Should you perform a digital vaginal examination in placenta praevia?

A

NO

Speculum exam may be helpful

42
Q

How is placenta praevia diagnosed?

A

Check anomaly scan
Confirm by TV USS
MRI to exclude accreta

43
Q

What is the management for placenta praevia that is not bleeding?

A

Advise pt to attend immediately if; bleeding (incl spotting), contractions, pain
NO sex
Antenatal corticosteroids between 34 and 35+6 weeks in women at high risk of preterm birth
Consider tocolysis if symptomatic placenta praevia or a low lying for 48 hours antenatal corticosteroids

44
Q

When should mag sulphate be given?

A

24-32 weeks if planning delivery

Neuroprotection

45
Q

How should delivery be planned in women who have placenta praevia but not bleeding?

A

34 - 36 weeks consider delivery if history of PV bleeding or other risk factors for preterm
Delivery timing tailored according to antenatal symptoms
Uncomplicated placenta praevia consider delivery between 36-37 weeks

46
Q

What is the management of bleeding placenta praevia?

A

Admit for 24 hours until bleeding has ceased
Anti-D if rh neg
Antenatal corticosteroids between 24-36 weeks
TEDS; no fragmin unless prolonged stay
Prevent and treat anaemia
JW; ensure advanced directive

47
Q

At what gestation can a CTG be used?

A

28 weeks

48
Q

When should a c/s be chosen of VD in placenta praevia?

A

c/s; if placenta covers os or <2cm from cervical os

Vaginal delivery if placenta >2cm from os and no malpresentation

49
Q

What is the issue surrounding c/s in placenta praevia?

A

Skin and uterine incision vertical <28 weeks if transverse lie
Aim to avoid cutting though the placenta

50
Q

What is placenta accreta?

A

A morbidly adherent placenta; abnormally adherent to the uterine wall

51
Q

What is placenta accreta associated with?

A

Severe bleeding
PPH
Hysterectomy

52
Q

What are major risk factors for the development of placenta accreta?

A

Placenta praevia

Prior c/s

53
Q

What is placenta increta?

A

Invading myometrium

54
Q

What is placenta percreta?

A

Penetrating uterus to bladder

55
Q

What is the MDT management of placenta accreta?

A

Prophylactic internal iliac balloon
Caesarean hysterectomy
Blood loss >3L expected
Conservative management - leave placenta in situ and give methotrexate

56
Q

What is a uterine rupture?

A

Full thickness opening of uterus including serosa

If serosa intact, it is dehiscence

57
Q

What are risk factors for a uterine rupture?

A

Previous c/s or uterine surgery
Multiparity and use of prostaglandins/ syntocinon
Obstructed labour

58
Q

Symptoms of uterine rupture?

A

Severe abdominal pain
Shoulder tip pain
Maternal collapse
PV bleeding

59
Q

Signs of uterine rupture?

A 
Intrapartum loss of contractions
Acute abdomen
Presenting part rises
Peritonism
IUD/ foetal distress
60
Q

What is the management of uterine rupture?

A 
Urgent ABCDE
2 large bore IV 
FBC, clotting, LFT, U+Es, Kleihauer (if rh neg) 
XM 4-6 units red packed cells
Initiate major haemorrhage protocol
IV fluids or transfuse 
Anti-D
61
Q

What is vasa praevia?

A

Unprotected foetal vessels transverse the membranes below the presenting part of the internal cervical os

62
Q

How is vasa praevia diagnosed?

A

Ultrasound transabdominal and TV with doppler

Clinically; ARM and sudden dark red bleeding with foetal bradycardia

63
Q

What is type 1 vasa praevia?

A

Vessel is connected to a velamentous umbilical cord

64
Q

What is type 2 vasa praevia?

A

Connected the placenta with a succenturiate or accessory lobe

65
Q

Risk factors for vasa praevia?

A

Placental anomalies such a bi-lobed placenta or succenturiate lobes where the foetal vessels run through the membranes joining the separate lobes
Hx of praevia
Multiple pregnancy
IVF

66
Q

What is the management of vasa praevia if diagnosed antenatally?

A

Antenatal diagnosis; steroids from 32 weeks, consider inpatient management if risks of preterm birth (32-34 weeks)
Deliver by c/s before labour (34-36 weeks)

67
Q

What is the management of vasa praevia if diagnosed whilst in labour?

A

Emergency c/s and neonatal resuscitation
Use of blood transfusion if required
Placenta for histology

68
Q

Aside from abruption, praevia, accreta and vasa praevia, what can cause APH?

A

Cervical; ectropion, polyp, carcinoma
Vaginal
Unexplained

69
Q

What is the definition of PPH?

A

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

70
Q

What is primary and secondary PPH?

A

Primary; within 24 hours

Secondary; after 24 hours to 6/52 post delivery

71
Q

What is minor PPH?

A

500-1000 ml blood loss

72
Q

What is major PPH?

A

> 1000 ml of signs of CV collapse or ongoing bleeding

73
Q

What are the 4 T’s of PPH?

A

Tone - uterine atony
Trauma - c/s, forceps, episiotomy
Tissue - retained tissue
Thrombin

74
Q

What are antenatal risk factors for PPH?

A 
Anaemia
Previous c/s 
Placenta praevia, percreta, accreta
Previous PPh
Previous retained placenta
Multiple pregnancy
Polyhydraminos
Obesity
Foetal macrosoia
75
Q

What are intrapartum risk factors for PPH?

A

Prolonged labour
Operative vaginal delivery
C/S
Retained placenta

76
Q

What can be done to prevent PPH?

A

Active management of 3rd stage; syntocinon IM/IV

77
Q

What should be examined when determining the aetiology of PPH?

A 
History
Exam
Uterine tone
Vaginal tears
Placenta and membranes; assess if there is likely to be any retained tissue
78
Q

Initial management of PPH?

A

Call for help
Assess
Stop bleeding
Fluid replacement

79
Q

Management for minor PPH?

A

IV access
G+S, FBC, coag screen incl fibrinogen
Obs; pulse, RR, BP every 15 mins
IV warmed crystalloid infusion

80
Q

How is a major PPH assessed?

A 
Vital signs; pulse, BP, cap refil, sats 
O2 
Determine cause; 4Ts 
Blood; FBC, clotting, fibrinogen, U+Es, LFTs, lactate 
XC 6 units 
Activate major haemorrhage protocol
81
Q

How can bleeding be stopped in PPH?

A 
Uterine massage; bimanual compression 
Expel clots
5 units IV syntocinon stat 
Infuse 40 units in 500ml hartmann's at 125 ml/hr (if PET; 40 units at 40 ml/hr) 
Foley catheter
MOST respond
82
Q

What should be done if pt has not responded to initial management for stopping bleeding in PPH?

A 
Confirm placenta and membranes complete
Urinary catheter
500 micograms ergometrine IV 
THEN 
Carboprost/ haemabate 250 mcg IM every 15 mins
Misoprostol 800 mcg PR
Tranexamic acid 0.5g-1g IV 
EUA in theatre if persistent bleeding
83
Q

What is the mode of carboprost?

A

Prostaglandin F2 alpha

84
Q

In what subset of patients is ergometrine contraindicated?

A

Cardiac disease

Hypertension; PET

85
Q

What is assessed in EUA in PPH?

A

Vaginal/ cervical trauma
Retained products of conception
Rupture
Inversion

86
Q

Non-surgical managements of stopping prolonged bleeding in PPH?

A

Packs and balloons; rusch, bakri
Tissue sealants
IR; arterial embolisation

87
Q

What are the surgical management of stopping prolonged bleeding in PPH?

A 
Under Suturing
Brace sutures; B-lynch 
Uterine artery ligation 
Internal iliac artery ligation 
Hysterectomy
88
Q

How should fluid be replaced in PPH?

A 
2 large bore IV 
Rapid fluid resuscitation; crystalloid 
Blood transfusion early 
If DIC/ coagulopathy; FFP, cryoprecipitate, platelets
Use blood warmer
Cell saver
89
Q

What investigation should be done for secondary PPH?

A

Exclude retained products of conception with USS

Likely to be infecion

90
Q

What is the management of patients post PPH?

A

Thromboprophylaxis
Debrief couple
Manage anaemia; IV rion
Datix and risk management

91
Q

What is kleihauer?

A

A test to determine if there has been and the size of foeto-maternal haemorrhage (FMH)
FMH estimation is is performed to ensure that pregnant women who have undergone potentially sensitising events are given adequate quantities of anti-D.
Will be positive if more than 4ml of foetal blood in maternal circulation

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