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Reproduction > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

what is the cut off for bleeding in early vs late pregnancy?

A 
early = <24 weeks 
late = >24 weeks
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2
Q

maternal mortality due to haemorrhage in UK is mainly static - true or false?

A

true

around 9 in 100,000

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3
Q

the placenta is entirely foetal tissue - true or false?

A

true

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4
Q

what are the functions of the placenta?

A

gas transfer
metabolism / waste disposal
hormone production
protective “filter”

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5
Q

what is the definition of antepartum haemorrhage (APH)?

A

bleeding from the genital tract

after 24 weeks gestation and before the end of 2nd stage of labour

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6
Q

what are the potential sources of an antepartum haemorrhage?

A

placental problem - previa / abruption

uterine problem - rupture

vasa previa

local causes - ectropion, cervical, vaginal

indeterminate

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7
Q

what are the potential differential diagnoses for APH?

A

heavy show
cystitis
haemorrhoids

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8
Q

how can APH be quantified?

A

spotting - staining, streaking, wiping
minor - <50ml
major - 50-1000ml (no shock)
massive - >1000ml (+/- shock)

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9
Q

what is placental abruption?

A

separation of a normally implanted placenta before birth of foetus

can be partially separated or totally separated

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10
Q

placental abruption is diagnosed clinically - true or false?

A

true

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11
Q

describe the pathology involved in placental abruption?

A

vasospasm then arteriole rupture into decidua
- blood escapes into amniotic sac OR under placenta AND into myometrium

tonic contractions occur which interrupts placental circulation and causes hypoxia

results in couvelaire (bruised) uterus

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12
Q

what are the risk factors for a placental abruption?

A 
pre-eclampsia / hypertension 
trauma / domestic violence / RTA
smoking 
drugs eg cocaine, amphetamin
medical conditions (thrombophilias, renal, diabetes)
polyhydramnios 
multiple pregnancy 
preterm prelabour rupture of membrane
abnormal placenta
previous abruption
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13
Q

what symptoms do patients suffering a placental abruption usually present with?

A

continuous severe abdominal pain (labour is intermittent)

backache if posterior placenta

bleeding (may be concealed)

pre-term labour

maternal collapse

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14
Q

what clinical signs may indicate a placental abruption?

A

unwell / distressed patient

uterus large for dates / normal

uterine tenderness (woody hard uterus)

foetal parts difficult to identify

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15
Q

describe the foetal heart rate and CTG abnormalities seen in a placental abruption?

A

foetal heart - bradycardia / absent (IUD)

CTG shows irritable uterus (1 contraction / minute) and foetal HR abnormality (loss of variation, decelerations)

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16
Q

how should a mother be resuscitated after a placental abruption?

A

2 large bore IV access

emergency bloods
- FBC, clotting, LFTs, U&Es, cross match 4-6 units, Kleihauer (for FMH, checks if anti D needed)

IV fluids (take care with PET / heart failure)

catheterise - hourly urine volumes

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17
Q

how should the foetus be managed in a placental abruption?

A

assess foetal heart - CTG then US if not heart

delivery - urgent c section or assisted rupture membranes and IOL

conservative management if minor

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18
Q

what are the potential complications of placental abruption for the mother?

A

hypovolaemic shock

anaemia due to blood loss

PPH (25%)

renal failure (renal tubular necrosis)

coagulopathy

infection

psychological (PTSD)

complications of blood transfusion

thromboembolism

mortality rare

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19
Q

what are the potential complications of placental abruption for the foetus?

A

intrauterine death (IUD)

hypoxia

prematurity

SGA and IUGR

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20
Q

how can placental abruption be prevented in high risk groups?

A

antiphospholipid syndrome = LMWH and low dose aspirin

smoking cessation

low dose aspirin

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21
Q

what is the difference between placenta praevia and a low lying placenta?

A

placenta praevia = placenta lies directly over internal Os

low lying placenta = placental edge <20mm from internal Os on transabdominal or transvaginal US

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22
Q

why is the placenta lying in the lower segment of the uterus a problem?

A

obstructs passage during labour

located in the part of the uterus which dilates to accommodate labour rather than contraction

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23
Q

previous c section and multiple c sections increase the risk of placenta praevia - true or false?

A

true

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24
Q

what other risk factors exist for placenta praevia?

A

previous placenta praevia

smoking

age (>40 years)

assisted reproductive technology

previous termination

multiparity

multiple pregnancy

deficient endometrium (endometritis, curettage, submucous fibroid)

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25
Q

how is placenta praevia screened for?

A

foetal anomaly scan includes placental localisation

rescan at 32 + 36 weeks if persistent placenta praevia or low lying placenta

assess cervical length <34 weeks for risk of preterm labour

MRI if placenta accreta suspected

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26
Q

what are the usual presenting symptoms of placental praevia?

A

painless bleeding >24 weeks

usually unprovoked (check for post-coital bleeding)

patients condition directly proportional to amount of observed bleeding

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27
Q

what clinical signs may indicate placenta praevia?

A

uterus soft non tender

presenting part high

malpresentations (as placenta is obstructing space to turn)

CTG usually normal

28
Q

how is placenta praevia diagnosed via investigation?

A

recheck anomaly scan

confirm by TVUS

MRI for excluding placenta accreta

29
Q

how is a mother with placenta praevia treated?

A

resuscitation if large blood loss

assess baby

conservative management if stable

admit if PV bleeding or distant from hospital or jehovah’s witness

prevent and treat anaemia

delivery plan in place

30
Q

if a patient with placenta praevia is not currently bleeding but the risk has been identified, how should she be managed?

A

advise patient to attend immediately if bleeding / spotting, contractions / pain (inc vague suprapubic period like pain)

antenatal corticosteroids <34 weeks of gestation in women at higher risk of preterm birth

Mg SO4 (neuro protection 24-32 weeks if planning delivery)

31
Q

if a mother has an uncomplicated placenta praevia with no PV bleeding, when should the baby ideally be delivered?

A

consider delivery between 36 and 37 weeks

32
Q

how should a mother with placenta praevia and a history of bleeding be resuscitated?

A

2 large bore IV access

emergency bloods
- FBC, clotting, LFT, U&Es, Kleihauer (Rh Neg), cross match 4-6 units of blood

major haemorrhage protocol if needed

IV fluids or transfuse blood

anti D (if Rh neg)

33
Q

which method of delivery of the baby is preferred in placenta praevia?

A

c-section = if placenta covers os or <2cm from os

vaginal delivery = if placenta >2cm from os and no malpresentation

34
Q

what further consent to you need before completing a c-section in placenta praevia?

A

consent to include hysterectomy and risk of general anaesthesia

cell salvage (collects blood from operating site)

35
Q

what surgical techniques are used in a placenta praevia c-section?

A

vertical skin and uterine incisions if <28 weeks and baby is lying transverse

aim to avoid cutting through the placenta

36
Q

what is placenta accreta?

A

morbidly adherent placenta - abnormally adherent to the uterine wall

37
Q

what are the major risk factors for placenta accreta?

A

placenta praevia

prior caesarian delivery

38
Q

what other names are given to placenta accreta if it is either invading the myometrium or penetrating to the bladder?

A

invading myometrium - increta

penetrating uterus to bladder - percreta

39
Q

how can placenta accreta be treated?

A

prophylactic internal iliac artery balloon

caesarean hysterectomy

conservative management (no surgery, just methotrexate)

40
Q

what is meant by a uterine rupture?

A

full thickness opening of uterus

41
Q

what are the potential risk factors for a uterine rupture?

A

previous c-section / uterine surgery eg myomectomy

multiparity and use of prostaglandins / syntocinon

obstructed labour

42
Q

how do patients normally present with uterine rupture?

A

severe abdominal pain

shoulder-tip pain

maternal collapse

PV bleeding

43
Q

what clinical signs may indicate uterine rupture?

A

loss of contractions during labour

acute pain in abdomen (peritonism)

presenting part rises

foetal distress / IUD

44
Q

how is uterine rupture urgently managed?

A

urgent resuscitation and surgical management

2 large bore IV access

bloods = FBC, clotting, LFT, U&Es, Kleihauer (if rh neg), cross match 4-6 units blood

major haemorrhage protocol

IV fluids or transfuse blood

anti D (if Rh neg)

45
Q

what is vasa praevia?

A

unprotected foetal vessels traverse the membranes below the presenting part - over the internal cervical Os

these rupture during labour or at amniotomy

46
Q

how is vasa praevia diagnosed on investigation?

A

transabdominal or transvaginal US (+ doppler)

47
Q

how can vasa praevia be diagnosed clinically?

A

assisted rupture of membranes and sudden dark red bleeding - foetal bradycardia / death

48
Q

how are the two types of vasa praevia that exist?

A

type I = vessel is connected to a velamentous umbilical cord

type II = connects the placenta with a succenturiate or accessory lobe

49
Q

what factors increase the risk of vasa praevia?

A

placental anomalies

  • bi-lobed placenta
  • succenturiate lobes (foetal vessels run through membranes joining separate lobes together)

history of low lying placenta in 2nd trimester

multiple pregnancy

IVF

50
Q

how is vasa praevia managed?

A

steroids from 32 weeks

inpatient management if risk of preterm birth (32-34 weeks)

deliver by elective c-section before labour (34-36 weeks)

emergency c-section and neonatal resuscitation + blood transfusion if required

send placenta to histology

51
Q

what other causes are responsible for APH?

A

cervical = ectropion, polyp, carcinoma

vaginal causes eg post-coital bleeding

52
Q

what is post-partum haemorrhage?

A

blood loss equal to or >500ml after birth of baby

53
Q

what is the difference between a primary and secondary PPH?

A

primary = within 24 hours of baby delivery

secondary = >24 hours after and within 6 weeks post delivery

54
Q

what volume is considered a minor vs major PPH?

A

minor - 500ml-1000ml (without shock)

major - >1000ml or signs of cardiovascular collapse or on-going bleeding

55
Q

why may blood loss may be underestimated in PPH?

A

not all blood loss is visual - patient may be bleeding into vagina but it is not visible except on examination

56
Q

what are the 4Ts which cause PPH?

A

tone 70%
trauma 20%
tissue 10%
thrombin <1%

57
Q

what are the risk factors for PPH?

A 
anaemia 
previous c section 
placenta praevia / accreta 
previous PPH
multiple pregnancy 
polydramnios / obesity / foetal macrosomia
58
Q

what do you need to make sure a patient who is a Jehova’s Witness has in place in a case of a PPH?

A

advanced directive (due to not accepting transfusions of blood)

some may accept cell salvage material as this is their own blood

59
Q

what intra-partum risk factors can precipitate PPH?

A 
prolonged labour 
operative vaginal delivery 
caesarean section 
retained placenta 
active management of third stage (oxytocin drugs)
60
Q

how do you treat a mother with PPH who has lost between 500-1000ml of blood but is not in shock?

A

IV access
bloods = FBC, coagulation screen + fibrinogen
observation = pulse, RR, BP every 15 minutes
IV warmed crystalloid infusion

61
Q

how is the bleeding in PPH stopped?

A

uterine massage - bimanual compression

expel clots

give oxytocin in Hartmann’s solution infused

if still bleeding = ergometrine IV (avoid if cardiac disease / hypertension)

if still bleeding = carboprost / haemabate IV every 15 min (max 8 doses), misoprostol and tranexamic acid

if still bleeding = examine under anaesthesia in theatre

62
Q

what other causes of PPH bleeding should be looked for in examination under anaesthesia in theatre?

A

vaginal / cervical trauma
retained products of conception
rupture
inversion

63
Q

how can PPH be managed after a patient has been taken to theatre?

A

non surgical

  • packs / balloons (bakri)
  • tissue sealants
  • interventional radiology (arterial embolisation)

surgical

  • undersuturing
  • brace sutures
  • uterine / internal iliac artery ligation
  • hysterectomy
64
Q

if a patient presents with a secondary PPH what cause do we want to rule out?

A

exclude retained products of conception (RPOC) with USS

65
Q

infection is likely to play a role in secondary PPH - true or false?

A

true

Reproduction (45 decks)

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