Bleeding in Late Pregnancy Flashcards
What is bleeding in early and late pregnancy
early <24 weeks (threatened miscarriage, not viable)
late > 24 weeks
what about fetus do you want to ask in bleeding in late pregnancy
changes in fetal movements
what is the most common indirect cause of maternal death
cardiac disease
what is the most common cause of direct maternal death
VTE
when does the placenta provide nutrients to the fetus
from week 6
what are the functions of the placenta and when is it fully functional
fully functional at 12 weeks
- gas transfer
- metabolism/ waste disposal
- hormone production (human placental lactogen)
- protective (filters toxins ingested by mother)
define an antepartum haemorrhage
bleeding from the genital tract after 24+0 weeks gestation and before the end of the second stage of labour (birth of baby)
what is the most common causes of antepartum haemorrhage
placental abruption and praevia
what can causes antepartum haemorrhage
placental praevia placenta abruption uterine rupture vasa praevia local causes: ectropion (when cervical glandular epithelium is present on vaginal aspect of cervix), polyp, infection, carcinoma
what are the differentials for an antepartum haemorrhage
heavy show
cystitis
haemorrhoids
how do you quantify an antepartum haemorrhage
spotting- staining, streaking, wiping
minor- <50 mls, settled
major- 50-1000ml, no shock
massive- >1000ml and/or shock
how is placental abruption diagnosed
clinically, cannot be confirmed by any Ix
what is placental abruption
separation of a normally implanted placenta partially or totally before birth of the fetus
what causes placental abruption
vasospasm followed by arteriole rupture into to decidua- blood escapes into the amniotic sac or further under the placenta and into myometrium
this causes tonic contraction and interrupts placental circulation = hypoxia (painful continuous contraction)
resutls in couvelaire uterus (has blueish appearance)
what are the risk factors for placental abruption
pre-eclampsia/ HPTx
trauma: blunt, forceful- domestic violence, RTA
smoking, cocaine, amphetamine
medical thrombophilias, renal diseases, diabetes
polyhydramnios, multiple pregnancy, preterm labour ROM
abnormal placenta
previous abruption
what are the symptoms of placental abruption
severe abdominal pain that is continuous (back ache with posterior placenta) bleeding- may be concealed preterm labour may present with maternal collapse
what are the signs of placental abruption
unwell distressed patient
signs may be inconsistent with revealed blood
uterus large for dates/ normal
uterine tenderness
woody, hard uterus
fetal parts may be difficult to identify (due to hard uterus)
may be in pre term labour (with heavy show)
fetal heart- bradycardia/ absent (IUD), CTG shows irritable uterus (1 contraction per minute, feta tachycardia, loss of variability, decelerations)
what is the management of placental abruption
resuscitate the mother - primary concern:
- 2 large bore IV access, FBC, clotting, LFT, U&Es, cross match 4-6 units RBS, kleihauer
- IV fluid (take care with PET)
- catheterise (measure hourly output with utometer)
assess and deliver the baby:
-assess fetal heart with CTG (USS if nor HB)
-delivery urgent, via CS, artificial rupture of membranes + IOL
-conservative delivery if haemorrhage minor
manage the complications
debrief the parents
what is the kleihauer test
determines whether there has been a fetal maternal haemorrhage and if so how large
what are the maternal complications of placental abruption
hypovolaemic shock anaemia PPH renal failure (from renal tubular necrosis) coagulopathy (FFP, cryoprecipitate) infection prolonged hospital stay psychological sequelae complications of blood transfusion thromboembolism (mortality rare)
what are the possible fetal complications of placental abruption
fetal death
hypoxia (brain injury)
prematurity (iatrogenic/ spontaneous)
small for dates/ IUGR
how can you prevent placental abruption
in APS- give LMWH and LDA smoking cessation LDA refer to drug misuse help services folic acid multiagency prevention for domestic violence
what is a placenta praevia
when the placenta lies directly over the internal os
what is a low lying placenta
when the placental edge is less than 20mm from the internal os on TA/TVUSS after 16 weeks gestation
what is the lower segment of the uterus
the part of the uterus below the utero-vesicle peritoneal pouch superiorly and internal os inferiorly
the part of the uterus that is 7cm from the level of the internal os
how is the lower segment of the uterus different from the upper
lower is thinner an contains less muscle fibres
lower doesn’t contract in labour but instead passively dilates
what increases the risk of placenta praevia
previous CS previous placenta praevia smoking ART maternal smoking previous TOP multiparity advanced maternal age (>40) multiple pregnancy deficient endometrium due to: uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid
what screening is done for placenta praevia
mid trimester fetal anomaly scan should include placental localisation
rescan at 32 and 36 weeks if persistent placenta praevia or LLP
(Transvaginal better than TA)
assess cervical length before 34 weeks for risk of preterm labour
MRI if placenta accreta suspected
what are the symptoms of placenta praevia
painless bleeding >24 weeks
(usually unprovoked but coitus can trigger it)
bleeding can be minor (spotting) or severe
patient condition is directly proportional to the amount of observed bleeding (unlike abruption which can be concealed)
fetal movements generally present
what are the signs of placenta praevia
uterus is soft and non tender
presenting part is high
malpresentation- breech, transverse, oblique
fetal heart CGT usually normal
what should you never do in suspected placenta praevia until it is excluded as a diagnosis
do not perform a digital vaginal or rectal exam
speculum exam may be useful
how is placenta praevia diagnosed
check anomaly scan
confirm by TVUSS
MRI to exclude placenta accreta
what is the general management for placenta praevia
resus mother- ABC
assess baby
conservative management if stable
admit if PV bleeding, distant from hopsital, transport problems, jehovahs witness (all should be inpatient for at least 24 hours until bleeding has ceased)
prevent and treat anaemia
delivery plan at/near term
anti D if rhesus -ve
antinatal steroids between 24+0 and 25+6 weejs
TEDs- no fragmin unless prolonged stay
ensure advanced directive with jehovahs witnesses
MgSO4 (neuroprotection 24-32 weeks if planning delivery)
what advise for non blleding patients with placenta praevia
advise to attend immediately if:
- bleeding (inc spotting)
- contractions
- pain (inc vague suprapubic period like aches)
no sex antenatal steroids (34+0 and 35+6 weeks or <34+0 weeks in high risk of preterm birth) consider tocolysis (delaying birth) if symptomatic MgSo4 neuroprotection (24-32 weeks- if planning delivery)
when should you aim to delivery in placenta praevia
34+0to 36+6weeks consider delivery if history of PV bleeding or other risk factors for preterm delivery.
Delivery timing tailored according to antenatal symptoms
Uncomplicated placenta praevia consider delivery between 36+0and 37+0weeks
what extra steps need to be taken in a patient with placenta praevia who is bleeding
cross match 4-6 RNC may need major haemorrhage protocol IV fluids/ tranfuse anti D expedite delivery (CS)
what needs to be considered in delivery planning in placenta praevia
if placenta covers os or <2cm from cervical os = CS
vaginal delivery if placenta >2cm from os and no malpresentation
if bleeding need quick delivery = CS
if doing CS:
Senior operator & Anaesthetist
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
what is placenta accreta
a morbidly adherent placenta - abormally adherent to the uterine wall
what increases risk of placenta accreta
5-10% of placenta praevia
multiple CS
what is placenta accreta associated with
severe bleeding
PPH
considerable maternal morbidity (always consultant in delivery)
what are the types of placenta accreta
invading the myometrium: increta
penetrating uterus to bladder: percreta
what is the management of placenta accreta
prophylatic internal iliac artery balloon
caesarean hysterectomy
blood loss >3 litres to be expected
conservative management (?+methotrexate)
what is a uterine rupture
full thickness opening of the uterus including the serosa
what is uterine dehiscence
opening of uterus but serosa is still intact
what are the risk factors for uterine rupture
previous C section/ uterine surgery
mulitparity and use of prostaglandins (IOL)/ syntocinon
obstructed labour
previous rupture
what are the symptoms of uterine rupture
severe abdominal pain
shoulder tip pain
maternal collapse
PV bleeding
what are the signs of uterine rupture
intra partum- loss of contractions acute abdomen presenting part rises loss of uterine contractions peritonism fetal distress, IUD
what is the management for uterine rupture
urgent resus and surgery 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)
what is vasa praevia
when unprotected fetal vessels traverse the membranes below the presenting part over the internal cervical os
these will rupture during labour or at amniotomy
how is vasa praevia diagnosed
TAUSS and TVUSS with doppler
clinically:
when artificial rupture of membranes causes sudden dark bleeding and fetal bradycardia/ death
what are the types of vasa praevia
type 1- when vessel is connected to a velamentous umbilical cord
type 2- when it connects the placenta with a succenturiate or accessory lobe
what are the risk factors for vasa praevia
placental anomalies such as bi lobed placenta or succenturiate lobes (where fetal vessels run through the membranes joining the separate lobes together)
Hx of low lying placenta in the second trimester
multiple pregnancy
in vitro fertilisation
what is the management for vaso praevia
Antenatal diagnosis-
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)
if APH caused by vasa praevia:
emergency CS
neonate resus (inc blood transfusion if required)
placenta for histology
what are the cervical causes of antepartum haemorrhage
ectropion
polyp
carcinoma
what are the vaginal causes of APH
trauma
how many APH’s have an unexplained cause
1/3rd
what is a post partum haemorrhage
blood loss = to or exceeding 500ml after the birth of the baby
- primary within 24hrs of delivery
- secondary >24hrs- 6 weeks post delivery
what are the classifications of PPH
primary - within 24hrs of birth
secondary- >24hrs- 6 weeks post partum
minor- 500ml-1000ml (without clinical shock)
major- >1000mls or signs of cardiovascular collapse/ ongoing bleeding
what should you always remember when quantifying PPH
visual blood loss may be underestimated
total blood volume depends on maternal body weight:
100mls/kg volume in pregnancy
what are the causes of PPH
the 4 T’s
tone- 70% caused by uterine atony
trauma- 20% (CS, instrumental delivery, episiotomy)
tissue- 10% (any placenta/ products of conception left in uterus)
thrombin- <1%
how do you prevent PPH
identify antenatal and intrapartum risk factors
active management of the 3rd stage of labour
what are the antenatal risk factors for PPH
anaemia previous CS placenta praevia, percreta, accreta previous PPH previous retained placenta multiple pregnancy polyhydramnios obesity fetal macrosomia (caution with JW, advanced directive)
what are the intrapartum risk factors for PPH
prolonged labour
operative vaginal delivery
CS
retained placenta
how is the third stage of labour actively managed
syntocinon/ syntometrine (IM/IV)
how do you identify the cause of a PPH
Hx exam uterine tone vaginal tears placenta and membranes
what is the initial management for a PPH
call for help assess; 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 stop bleeding fluid replacement
what measures should be taken in a minor PPH (500-1000ml no shock)
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
how do you stop the bleeding in PPH
Uterine massage- bimanual compression Expel clots 5 units IV Syntocinon stat 40 units Syntocinon in 500ml Hartmann's - 125 ml/h Foleys Catheter
if still bleeding
Confirm placenta and membranes complete (nothing left inside)
Urinary Catheter
500 micrograms Ergometrine IV (Avoid if Cardiac Disease / Hypertension) (these are oxytocics)
? Vaginal / perineal trauma - ensure prompt repair
? cervical trauma
still bleeding
Carboprost /Haemabate ( PGF2α) 250mcg IM every 15min ( Max 8 doses) (prostaglandin)
Misoprostol 800mcg PR (these are oxytocics)
Tranexamic acid 0.5g-1g IV
EUA in theatre if persistent bleeding
CALL CONSULTANT
Transfer to Maternity Operating Theatre for EUA ? Vaginal / cervical trauma. ? Retained Products Of Conception ? Rupture ? Inversion Allows advanced techniques
what are the non surgical mechanisms for stopping bleeding in PPH
Packs & Balloons – Rusch Balloon, Bakri Balloon
Tissue Sealants
Interventional Radiology : Arterial Embolisation
what are the surgical mechanisms for stopping bleeding in PPH
Undersuturing Brace Sutures – B-Lynch Suture Uterine Artery Ligation Internal Iliac Artery Ligation Hysterectomy
how is fluid replaced in PPH
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
what should you consider in secondary PPH
Retained products of conception (RPOC)- exclude with USS
Infection likely to play a role
what should you always remember to do in APH
kelinauer
anti D
steroids
what do most women respond to in PPH
uterotonic agents
