Bleeding in Late Pregnancy # Flashcards
What defined bleeding in late pregnancy?
> 24 weeks
What are good questions to ask about bleeding in pregnancy?
Amount Colour Is pain continuous or intermittent MEWS score Any trigger; esp coital Foetal movements
What direct cause of pregnancies causes the most deaths in the 6 weeks postpartum?
VTE
When does the placenta form, and when is it fully functional?
Forms 6 weeks
Functional at 12 weeks
What are the functions of the placenta?
Gas transfer
Metabolism/ wast disposal
Hormone production (hPL)
Protective “filter”
What is the definition of APH?
Bleeding from genital tract after 24 weeks gestation and before the end of the 2nd stage of labour
What are the commonest causes of APH?
Abruption
Previa
What can cause APH?
Placenta issues; praevia, abruption Uterine problem; rupture Indeterminate Vasa praevia Local; ectropion, polyp, infection, carcinoma
DDx of APH?
Heavy show
Cystitis
Haemorrhoids
What is the “show”?
Mucus plug comes away indicating start of labour
How can APH be quantified?
Spotting; staining, streaking, wiping
Minor; <50ml
Major; 50-1000ml
Massive; >1000ml and/or shock
What is a placental abruption?
Premature separation of a normally implanted placenta partially or totally before the birth of the foetus
Is an abruption a clinical or investigative diagnosis?
Clinical
How many pregnancies will an abruption complicate and what percentage of APH is due to ab abruption?
1% of pregnancies
40% of APH
What is the pathology of an abruption?
Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into the myometrium
Why is an abruption painful?
Results in tonic contraction and interrupts placental circulation which results in hypoxia
What is a couvelaire uterus?
Blue appearance to uterus due to bruising
Risk factors for development of a placental abruption?
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
What are the symptoms of a placental abruption?
Severe abdo pain; CONTINUOUS Backache with posterior placenta Bleeding (may be concealed if retroplacental) Preterm labour Maternal collapse
Signs of a placental abruption on examination?
Uterus large for dates or normal
Uterine tenderness
Woody hard uterus
Can be in preterm labour with heavy show
What condition will the foetus be in in placental abruption?
Foetal heart; bradycardia/ absent (IUD)
CTG; irritable uterus (1 contraction per min, FH abnormality, tachycardia, loss of variability, decelerations)
Basic management of a placental abruption?
Resuscitate mother
Assess and deliver baby
Manage complications
Debrief the parents
How should the mother be resuscitated in a placental abruption?
2 large bore IVs Bloods; FBC, clotting, LFT, U+Es, XM 4-6 units packed red cells Kleihauer IV fluids (careful with PET) Catheterise
How should delivery be managed in a placental abruption?
Urgent delivery by c/s
ARM and induction of labour
Expectant/ conservative management (only for minor; allow steroid cover)
What are the maternal complications of a placental abruption?
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
Foetal complications of placental abruption?
Foetal death; IUD
Hypoxia
Prematurity; iatrogenic or spontaneous
SGA and FGR
Can abruptions be prevented in future pregnancies?
Recurrence is 10% APS; LMWH and LDA Drug misuse; referral to drug misuse agencies Smoking cessation Folic acid Domestic violence
What is a placenta praevia?
Placental lies directly over internal os
When should the term low lying placenta be used in place of placenta praevia?
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)
Anatomically, what is the lower segment of the uterus?
Part of uterus below the utero-vesical peritoneal pouch superiorly and the internal os inferiorly
Thinner and contains less muscle fibres than upper segment
Physiologically, what is the lower segment of the uterus?
Part of uterus which does not contract in labour but passively dilates
Metrically, what is the lower segment of the uterus?
Part of uterus which is about 7cm from the level of the internal os
What percentage of APH is due to praevia?
20%
What is a big RF for placenta praevia?
C/s - increased risk in future pregnancies
What are the risk factors for placenta praevia?
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
When is placenta praevia screened for?
20 week; midtrimester foetal anomaly scan should include placental localisation
When will you be rescanned if praevia is identified at the 20 week scan?
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
What should be performed if placenta accreta is suspected?
MRI
What are the symptoms of placenta praevia?
Painless bleeding >24 weeks
Usually unprovoked by coitus can trigger
Bleeding can be minor or severe
What are the signs of placenta praevia on examination?
Uterus soft and non-tender
Presenting part is high
Malpresentations - breech/ transverse/ oblique
Foetal heart; CTG normal
Should you perform a digital vaginal examination in placenta praevia?
NO
Speculum exam may be helpful
How is placenta praevia diagnosed?
Check anomaly scan
Confirm by TV USS
MRI to exclude accreta
What is the management for placenta praevia that is not bleeding?
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
When should mag sulphate be given?
24-32 weeks if planning delivery
Neuroprotection
How should delivery be planned in women who have placenta praevia but not bleeding?
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
What is the management of bleeding placenta praevia?
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
At what gestation can a CTG be used?
28 weeks
When should a c/s be chosen of VD in placenta praevia?
c/s; if placenta covers os or <2cm from cervical os
Vaginal delivery if placenta >2cm from os and no malpresentation
What is the issue surrounding c/s in placenta praevia?
Skin and uterine incision vertical <28 weeks if transverse lie
Aim to avoid cutting though the placenta
What is placenta accreta?
A morbidly adherent placenta; abnormally adherent to the uterine wall
What is placenta accreta associated with?
Severe bleeding
PPH
Hysterectomy
What are major risk factors for the development of placenta accreta?
Placenta praevia
Prior c/s
What is placenta increta?
Invading myometrium
What is placenta percreta?
Penetrating uterus to bladder
What is the MDT management of placenta accreta?
Prophylactic internal iliac balloon
Caesarean hysterectomy
Blood loss >3L expected
Conservative management - leave placenta in situ and give methotrexate
What is a uterine rupture?
Full thickness opening of uterus including serosa
If serosa intact, it is dehiscence
What are risk factors for a uterine rupture?
Previous c/s or uterine surgery
Multiparity and use of prostaglandins/ syntocinon
Obstructed labour
Symptoms of uterine rupture?
Severe abdominal pain
Shoulder tip pain
Maternal collapse
PV bleeding
Signs of uterine rupture?
Intrapartum loss of contractions Acute abdomen Presenting part rises Peritonism IUD/ foetal distress
What is the management of uterine rupture?
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
What is vasa praevia?
Unprotected foetal vessels transverse the membranes below the presenting part of the internal cervical os
How is vasa praevia diagnosed?
Ultrasound transabdominal and TV with doppler
Clinically; ARM and sudden dark red bleeding with foetal bradycardia
What is type 1 vasa praevia?
Vessel is connected to a velamentous umbilical cord
What is type 2 vasa praevia?
Connected the placenta with a succenturiate or accessory lobe
Risk factors for vasa praevia?
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
What is the management of vasa praevia if diagnosed antenatally?
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)
What is the management of vasa praevia if diagnosed whilst in labour?
Emergency c/s and neonatal resuscitation
Use of blood transfusion if required
Placenta for histology
Aside from abruption, praevia, accreta and vasa praevia, what can cause APH?
Cervical; ectropion, polyp, carcinoma
Vaginal
Unexplained
What is the definition of PPH?
Blood loss equal to or exceeding 500ml after birth of the baby
What is primary and secondary PPH?
Primary; within 24 hours
Secondary; after 24 hours to 6/52 post delivery
What is minor PPH?
500-1000 ml blood loss
What is major PPH?
> 1000 ml of signs of CV collapse or ongoing bleeding
What are the 4 T’s of PPH?
Tone - uterine atony
Trauma - c/s, forceps, episiotomy
Tissue - retained tissue
Thrombin
What are antenatal risk factors for PPH?
Anaemia Previous c/s Placenta praevia, percreta, accreta Previous PPh Previous retained placenta Multiple pregnancy Polyhydraminos Obesity Foetal macrosoia
What are intrapartum risk factors for PPH?
Prolonged labour
Operative vaginal delivery
C/S
Retained placenta
What can be done to prevent PPH?
Active management of 3rd stage; syntocinon IM/IV
What should be examined when determining the aetiology of PPH?
History Exam Uterine tone Vaginal tears Placenta and membranes; assess if there is likely to be any retained tissue
Initial management of PPH?
Call for help
Assess
Stop bleeding
Fluid replacement
Management for minor PPH?
IV access
G+S, FBC, coag screen incl fibrinogen
Obs; pulse, RR, BP every 15 mins
IV warmed crystalloid infusion
How is a major PPH assessed?
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
How can bleeding be stopped in PPH?
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
What should be done if pt has not responded to initial management for stopping bleeding in PPH?
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
What is the mode of carboprost?
Prostaglandin F2 alpha
In what subset of patients is ergometrine contraindicated?
Cardiac disease
Hypertension; PET
What is assessed in EUA in PPH?
Vaginal/ cervical trauma
Retained products of conception
Rupture
Inversion
Non-surgical managements of stopping prolonged bleeding in PPH?
Packs and balloons; rusch, bakri
Tissue sealants
IR; arterial embolisation
What are the surgical management of stopping prolonged bleeding in PPH?
Under Suturing Brace sutures; B-lynch Uterine artery ligation Internal iliac artery ligation Hysterectomy
How should fluid be replaced in PPH?
2 large bore IV Rapid fluid resuscitation; crystalloid Blood transfusion early If DIC/ coagulopathy; FFP, cryoprecipitate, platelets Use blood warmer Cell saver
What investigation should be done for secondary PPH?
Exclude retained products of conception with USS
Likely to be infecion
What is the management of patients post PPH?
Thromboprophylaxis
Debrief couple
Manage anaemia; IV rion
Datix and risk management
What is kleihauer?
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
