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1. Reproduction > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

What constitutes late pregnancy?

A

> 24 weeks

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2
Q

What can cause an antepartum haemorrhage?

A 
vasa previa
placenta
previa
placental abruption
uterine rupture
cystitis
haemorrhoids
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3
Q

How common is antepartum haemorrhage?

A

3-5% of pregnancies

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4
Q

What is an antepartum haemorrhage?

A

bleeding from the genital tract after 24 weeks gestation + before the end of the second stage of labour

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5
Q

What are the functions of the placenta?

A

gas transfer
metabolism/waste disposal
protective filter
hormone production - HPL

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6
Q

What ml of blood quantifies a minor APH?

A

<50ml

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7
Q

What ml of blood quantifies a major APH?

A

50-1000ml

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8
Q

What ml of blood quantifies a massive APH?

A

> 1000ml and/or shock

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9
Q

What is placental abruption?

A

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

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10
Q

What % of APHs are placental abruptions?

A

40%

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11
Q

What is the pathophysiology behind placental abruptions?

A

vasospasm followed by an arteriole rupture into the decidua
blood escapses into the amniotic sac of further under the placenta and into the myometrium
this cause. tonic contraction which causes pain and interrupts placental circulation

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12
Q

What does placental abruption result in?

A

couverlaire uterus - blueish appearance

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13
Q

What are the risk factors for placental abruption?

A 
mostly unknown
PET
blunt or forceful trauma
smoking/cocaine/amphetamine
medical thrombophilias/renal disease/diabetes
polyhydroamnios/mutliple pregnancies/pre term rupture of membranes
abnormal placenta
previous abruption - 10% recurrence rate
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14
Q

What are the symptoms of placental abruption?

A 
continuous severe abdominal pain
maternal collapse
backache with posterior placenta
bleeding
preterm labour
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15
Q

What are the signs of placental abruption?

A 
HARD WOODY TENDERNESS
unwell, distressed patient,
fetal parts hard to identify - heart sounds bradycardic or absent
CTG shows irritable uterus
preterm labour w/ heavy show
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16
Q

How is placental abruption managed?

A

resuscitate mother
assess and deliver baby
2 large bore IV access cannulas, cross match 4-6 units red packed cells
if stable - induce labour by amniotomy
if unstable - delivery by catagory 1 c/section
steroids for baby

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17
Q

What are maternal complications of placental abruption?

A 
hypovolaemic shock
PPH - 25%
anaemia
renal failure
coagulopathy
infection
thromboembolism
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18
Q

What are foetal complications of placental abruption?

A 
death - 14%
hypoxia
prematurity
SGA
growth restriction
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19
Q

How can placental abruption be prevented?

A

smoking cessation
APS - give LDA
stop drug misuse

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20
Q

What % of APHs are placenta previa?

A

20%

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21
Q

What is placenta previa?

A

placenta lies directly over the internal os

after 16weeks the term low lying placenta is used when the placental edge is less than 20mm from the internal os

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22
Q

How far away from the internal os is the placenta usualy?

A

7cm

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23
Q

What are the characteristics of the lower segment of the placenta?

A

thinner
contains less muscle fibres than the upper segment
doesnt contract in labour, it passively dilates

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24
Q

What are the risk factors of placenta previa?

A 
previous placenta previa
smoking
c/section delivery
assisted reproduction
multiparty
previous TOP
deficient endometrium due to presence of uterine scars or endometritis
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25
Q

When is placenta previa screened for?

A

mid trimester fetal anomaly scan - 20 weeks

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26
Q

If placenta previa is picked up at 20 weeks, when do you re scan for it?

A

32 and 36 weeks

27
Q

What is the best USS method for placenta previa?

A

transvaginal

28
Q

What should you do if placenta accreta is suspected?

A

MRI

29
Q

What are the symptoms of placenta previa?

A

painless bleeding - pts condition is directly proportional to the amount of bleeding
sex can trigger bleeding

30
Q

What are the signs of placenta previa?

A

uterus soft non tender
CTG normal
presenting part high
mal presentation

31
Q

What must you never do until you exclude placenta previa?

A

perform a digital exam

32
Q

How is placenta previa diagnosed?

A

transvaginal USS

33
Q

How do you manage placenta previa?

A 
if unstable - ABCDE and assess baby
admit to hospital if PV bleeding
TEDS
give steroids between 34-35+6
magnesium sulfate for neural protection - 24-32 weeks
34
Q

When should you deliver a baby in placenta previa?

A

if history of PV bleeding = 34-36+6
if uncomplicated = 36-37+0
need cross match bloods and haemorrhage protocol

35
Q

When would you do a c/section in placenta previa?

A

if placenta covers os or = 2cm from os

36
Q

What is placenta accreta?

A

morbidly adherant placenta to the uterine wall

37
Q

What % of placenta previas are placenta accreta?

A

5-10%

38
Q

What is placenta increta?

A

placenta invading the myometrium

39
Q

What is placenta pancreta?

A

placenta invading the bladder

40
Q

What is placenta accreta associated with?

A

severe bleeding
PPH
ending up having a hysterectomy

41
Q

How is placenta accreta managed?

A

prophylactic internal iliac artery baloon
cesarean hysterectomy
blood loss >3L expected

42
Q

What are the risk factors for placenta accreta?

A

placenta previa

previous c/section

43
Q

What is a uterine rupture?

A

full thickness opening of the uterus

44
Q

What causes uterine rupture?

A 
uterine surgery - myomectomy
obstructed labour
multiparity + use of prostaglandins/syntocinon 
1 in 250 if induction of labour
1 in 500 with previous c/section
45
Q

What are the symptoms of uterine rupture?

A

severe abdo pain
shoulder tip pain
maternal collapse
PV bleeding

46
Q

What are the signs of uterine rupture?

A

loss of contractions
presenting part rises
peritonism
foetal distress/intrauterine death

47
Q

How is uterine rupture managed?

A

same as placenta previa and accreta

48
Q

What is vasa previa?

A

AN EMERGENCY - mortality 60%
unprotected foetal vessels transverse the membranes below the presenting part over the internal cervical os
these rupture during labour or at amniotomy causing a foetal haemorrhage

49
Q

How is vasa previa diagnosed?

A

USS TA and TV with a doppler

50
Q

How does vasa previa present?

A

artificial rupture of membranes and sudden dark red bleeding and foetal bradycardia

51
Q

What is type 1 vasa previa?

A

connected to a velamentous umbillical cord

52
Q

What is type 2 vasa previa?

A

when it connects to the placenta with a succentiate or accessory lobe

53
Q

What are the risk factors of vasa previa?

A

placental abnormalities - bilobed
history of low lying placenta in 2nd trimester
multiple pregnancy
IVF

54
Q

How is vasa previa managed?

A

steroids from 32 weeks
emergency c/section and neonatal resuscitation if rupturesd vasa previa during labour
deliver by c/section before labour ideally
placenta for histology

55
Q

What is a post partum haemorrhage?

A

blood loss of >500mls after the birth of the baby

56
Q

What constitutes a primary PPH?

A

within 24hours of delivery

57
Q

What constitutes a secondary PPH?

A

> 24hours -> 6 weeks post delivery

58
Q

What is a minor PPH?

A

500-1000ml

59
Q

What is a major PPH?

A

> 1000ml or signs of cardiovascular collapse

60
Q

What causes a PPH?

A 
4 Ts!!
Tone - 70% - uterine atony
Trauma - 20% - c/sections and forceps
Tissue - 10% - episiotomy
Thrombin - < 1%
61
Q

What are risk factors for a PPH?

A 
anaemia
previous c/section, placenta previa or accreta, PPH, retained placenta
polyhydroamnios
obesity 
fetal macrosomnia
62
Q

What are intrapartum risk factors for PPH?

A

prolonged labour
operative vaginal delivery
c/section
retained placenta

63
Q

What can be used as prophylaxis of PPH?

A 
uterotonic agents:
5 units IV syntocinon + foleys catheter
500mg ergometrine IV
carbopost/haemabate 250mg every 15 mins IM
misoprostol 500mg PR
tranexamic acid 0.5-1g IV
64
Q

What can be done to stop the bleeding in PPH?

A

uterine massage
surgery - sutures, uterine artery ligation, internal iliac artery ligation, hysterectomy
packs and balloons, arterial embolisation

1. Reproduction (50 decks)

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