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Reproductive & Sexual Health > Bleeding in Late Pregnancy > Flashcards

Bleeding in Late Pregnancy Flashcards

1
Q

What is the definition of bleeding in early pregnancy?

A

<24 weeks

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2
Q

What is the definition of bleeding in late pregnancy?

A

Antepartum haemorrhage - UK >/= 24 weeks

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3
Q

When does the placenta become the foetus’ main source of nutrition?

A

From 6 weeks

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4
Q

What are the functions of the placenta?

A
  • Gas transfer
  • Metabolism/waste disposal
  • Hormone production (HPL & hGh-V)
  • Protective ‘filter’
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5
Q

What is the definition of antepartum haemorrhage?

A
  • Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
  • bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby
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6
Q

What are the commonest causes of APH?

A

Placental abruption and placenta praevia

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7
Q

What is the aetiology of APH?

A
  • Placental problem
    • praevia
    • abruption
  • Uterine problem
    • rupture
  • indeterminate
  • vasa praevia
  • local causes
    • infection
    • ectropion
    • polyp
    • carcinoma
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8
Q

What is the DDx of APH?

A
  • Heavy show
  • Cystitis
  • Haemorrhoids
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9
Q

What is spotting

A

Blood staining, streaking or on wiping

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10
Q

What is minor APH?

A

<50ml settled

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11
Q

What is major APH?

A

50-1000ml no shock

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12
Q

What is massive APH?

A

>1000ml and/or shock

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13
Q

What is placental abruption?

A

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

CLINICAL DIAGNOSIS

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14
Q

Placental abruption occurs in _% of pregnancies

Placental abruption occurs in __% of APH

A

Placental abruption occurs in 1% of pregnancies

Placental abruption occurs in 40% of APH

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15
Q

What is the pathophysiology of placental abruption?

A
  • vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into myometrium
  • causes tonic contraction and interrupts placental circulation which causes hypoxia
  • results in couvelaire uterus
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16
Q

What are the risk factors for placental abruption

A
  • 70% have no risk factors
  • pre-eclampsia/hypertension
  • trauma- blunt, forceful- domestic violence/RTA
  • smoking/cocaine/amphetamine
  • medical thrombophilias/renal disease/diabetes
  • polyhydramnios
  • multiple pregnancy
  • preterm-PROM
  • abnormal placenta
  • previous abruption
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17
Q

What are the symptoms of placental abruption?

A
  • severe continuous abdominal pain
  • backache with posterior placenta
  • bleeding (may be concealed)
  • preterm labour
  • maternal collapse
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18
Q

What are the abdominal signs of placental abruption?

A
  • uterus LFD or normal
  • uterine tenderness
  • woody hard uterus
  • fetal parts difficult to identify
  • may be in preterm labour (with heavy show)
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19
Q

What are the signs of placental abruption in the foetus?

A
  • fetal heart rate: bradycardia/absent (intrauterine death)
  • CTG shows irritable uterus
    • 1 contraction/minute
    • FH abnormality- tachycardia, loss of variablility, decelerations
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20
Q

Describe the management of placental abruption

A
  • resuscitate mother
  • assess & deliver the baby
  • manage the complications
  • debrief the parents
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21
Q

Describe resuscitation of mother in placental abruption

A

2 large bore IV access

Bloods: FBC, clotting, LFT U&Es, Xmatch 4-6 units RBC, kleihauer (Fetal Hb in mum)

IV fluids

Catheterise- urometer

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22
Q

What are the maternal complications of placental abruption?

A
  • hypovolaemic shock
  • anaemia
  • PPH
  • renal failure from renal tubular necrosis
  • coagulopathy (FFP, cryoprecipitate)
  • infection
  • complications of blood transfusion
  • thromboembolism
  • prolonged hospital stay
  • psychological sequelae
  • mortality- rare
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23
Q

What are the foetal complications with Placental abruption?

A
  • IUD (14%)
  • hypoxia
  • prematurity- iatrogenic & spontaenous
  • small for gestational age and foetal growth restriction
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24
Q

What is the treatment of anti-phospholipid syndrome causing placental abruption?

A

LMWH & LDA

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25
Q

What is placenta praevia

A

When the placental lies directly over the internal os

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26
Q

What is low-lying placenta

A

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

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27
Q

What is the anatomical lower segment of the uterus?

A
  • the part of the uterus below the utero-vesical peritoneal pouch superiorly and the internal os inferiorly
  • thinner and ocntains less muscle fibres than the upper segment
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28
Q

What is the physiological lower segment of the uterus?

A

The part of the uterus which does not contract in labour but passively dilates

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29
Q

What is the metric lower part of the uterus?

A

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

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30
Q

Placenta praevia is present in __% of APH

A

20

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31
Q

_________ delivery is associated with an increased risk of placenta praevia in subsequent pregnancies

A

Caesarean delivery is associated with an increased risk of placenta praevia in subsequent pregnancies

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32
Q

What are the risk factors for placenta praevia?

A
  • previous c/section
    • 1 C/S or 2.2
    • 2C/S or 4.1
    • 3C/S or 22.4
  • previous TOP
  • advanced maternal age (>40 years)
  • multiparity
  • assisted conception
  • mulitple pregnancy
  • smoking
  • deficient endometrium due to presence or history of;
    • uterine scar, endometritis, manual removal or placenta, curettage, submucous fibroid
33
Q

How is placenta praevia screened for?

A
  • midtrimester fetal anomaly scan should include placental localisation
  • rescan at 32 and 36 weeks if persistent PP or LLP
  • transvaginal scan superior to transabdominal scan
  • assess cervical length before 34 weeks for risk of preterm labour
  • MRI if placenta accreta suspected
34
Q

What are the symptoms of placenta praevia?

A
  • painless bleeding
  • usually unprovoked but coitus can trigger bleeding
  • bleeding can be minor e.g. spotting/severe
  • foetal movements usually present
35
Q

What are the signs of placenta praevia?

A
  • general
    • proportional symptoms to amount of bleeding
  • abdomen
    • uterus soft non-tender
    • presenting part high
    • malpresentations- breech/transverse/oblique
  • fetal heart
    • CTG usually normal
36
Q

When can vaginal examination be performed if placenta praevia suspected?

A

Only after it is excluded

37
Q

How is placenta praevia diagnosed?

A
  • CHECK anomaly scan
  • confirm by TVUS
  • MRI for excluding placenta accreta
38
Q

How is placenta praevia managed?

A
  • resuscitation of mother: ABC
  • assess babies condition
  • investigations
  • steroids 24-35+ 6 weeks
  • Anti D if rhesus negative
  • conservative management if stable
  • admit for at least 24 hours until bleeding has ceased
  • TEDS- no fragmin unless prolonged stay
  • prevent & treat anaemia
  • delivery plan
    • MgSO4 (neuroprotection 24-32 weeks if planning delivery)
39
Q

When should patients attend immediately (previous diagnosis of placenta praevia)?

A

Any bleeding including spotting

Contractions or pain

40
Q

What can patients with placenta praevia not do

A

have sex

41
Q

When should delivery be considered in placenta praevia?

A
  • consider at 34+0 to 36+6 weeks if history of PVB or any other risk factors for preterm delivery
  • delivery timed to symptoms
  • uncomplicated placenta praevia consider delivery between 36+0 and 37+0 weeks
42
Q

What is the management of a bleeding mother with placenta praevia?

A
  • communication (MW, Obstetrics, anaesthetics, NNU, theatre, haematology)
  • 2 large bore IV access
  • FBC, clotting, LFT, U&E. Kleihauer (if Rh neg)
  • Xmatch 4-6 units RBC
  • may need major haemorrhage protocol
  • IV fluids or transfuse
  • Anti D if Rh -ve
  • expedite delivery
43
Q

How can delivery be planned in placenta praevia?

A
  • C/section : if placenta covers os or <2cm from cervical os
  • Vaginal delivery if placenta >2cm from os and no malpresentation
44
Q

Describe c/section planning in placenta praevia?

A
  • Senior surgeon & Anaesthetist
  • Consent to include hysterectomy and risk of GA
  • Cell salvage
  • Skin and uterine incisions vertical <28 weeks if transverse lie
  • Aim to avoid cutting through the placenta
45
Q

What is placenta accreta?

A

A morbidly adherent placenta: abnormally adherent to the uterine wall

46
Q

What increases the risk of placenta accreta?

A

Multiple c/sections

47
Q

What is placenta accreta associated with?

A

Severe bleeding, PPH and may end up having hysterectomy

48
Q

What is increta?

A

Invasion of myometrium

49
Q

What is percreta?

A

Penetrating uterus to bladder

50
Q

Describe the management of placenta accreta?

A
  • Prophylactic internal iliac artery balloon
  • Caesarean hysterectomy
  • Blood loss >3L expected
  • Conservative Management (?plus Methotrexate)
51
Q

What increases the risk of uterine rupture

A
  • previous c/sections
  • IOL
  • previous rupture
52
Q

Define uterine rupture?

A

Full thickness opening of uterus

Including serosa

If serosa is intact- dehiscence

53
Q

What are the symptoms of uterine rupture?

A
  • severe abdominal pain
  • shoulder-tip pain
  • maternal collapse
  • PV bleeding
54
Q

What are the signs of uterine rupture?

A
  • intra-partum= loss of contractions
  • acute abdomen
  • PP rises
  • loss of uterine contractions
  • peritonism
  • fetal distress/IUD
55
Q

what is the management of uterine rupture?

A
  • urgent resuscitation & surgical managment
  • communication (MW, Obstetrics, anaesthetises, NNU, theatre, haematologist)
  • 2 large bore IV access
  • FBC, clotting, LFT, U&E, Kleihauer (if Rh negative)
  • Xmatch 4-6 units of RBC
  • May need MHP
  • IV fluids or transfuse
  • Anti D (if Rh Neg)
56
Q

Define vasa praevia

A
  • unprotected fetal vessels transverse the membranes below the presenting part over the cervical os
57
Q

What is the problem with vasa praevia?

A

Will rupture during labour or at amniotomy

58
Q

How is vasa praevia diagnosed?

A

US TA & TV with doppler

Clinical- ARM and sudden dark red bleeding, fetal bradycardia/death

59
Q

What is type I vasa praevia?

A

When the vessel is connected to a velamentous umbilical cord

60
Q

What is type II vasa praevia?

A

When it connects the placenta with a succenturiate or accessory lobe

61
Q

What are the risk factors for placenta praevia?

A
  • placental anomalies such as a bilobed placenta or succenturiate lobes where the fetal vessels run through the membranes joining the separate lobes together
  • a history of low-lying placenta in the second trimester
  • multiple pregnancy
  • IVF
62
Q

What is the management of vasa praevia?

A
  • antenatal diagnosis
  • steroid from 32 weeks
  • consider inpatient management if risks of preterm birth (32-34 weeks)
  • delivery by elective c/section before labour (34-36 weeks)
  • APH from vasa praevia is an emergency: c/s
  • Placenta for histology
63
Q

Define post-partum haemorrhage?

A

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

64
Q

Define primary and secondary PPH

A
  • Primary
    • within 24hr of delivery
  • secondary
    • >24h-6/52 post delivery
65
Q

Define minor and major PPH

A
  • minor
    • 500-1000ml (without clinical shock)
  • major
    • >1000ml or other signs of CV collapse or on-going bleed
66
Q

What are the 4 T’s?

A

Causes of PPH

  • tone 70%
  • trauma 20%
  • tissue 10%
  • thrombin <1%
67
Q

What are the risk factors for PPH

A
  • anaemia
  • previous c/s
  • placenta praevia, percreta, accreta
  • previous PPH
  • previous retained placenta
  • multiple pregnancy
  • polyhydramnios
  • obesity
  • foetal macrosomia
68
Q

What are the intrapartum risk factors for PPH

A
  • prolonged labour
  • operative vaginal delivery
  • caesarean section
  • retained placenta
  • active managment of third stage
    • syntocinon/syntometrine IM/IV
69
Q

What is the initial management of PPH

A
  • call for helo
  • assess
  • stop bleeding
  • fluid replacement
70
Q

Describe management of minor PPH

A
  • IV access (one 14-guage cannula)
  • G&S, FBC, coagulation screen, including fibrinogen
  • Obs: pulse respiratory rate and blood pressure recording every 15 minutes
  • IV warmed crystalloid infusion
71
Q

What is assessed in PPH

A
  • vital signs: pusle, BP, CRT, sats every 15 min
  • give oxygen
  • determine cause of bleeding- 4Ts
  • blood samples: FBC, clotting, fibrinogen, U&E, LFT, lactate
  • crossmatch 6 units packed red cells
  • may need MHP
72
Q

How can the bleeding be stopped in PPH?

A
  • uterine massage- bimanual compression
  • expel clots
  • 5 units IV syntocinon stat 40 units
  • Syntocinon in 500ml Hartmanns- 125ml/h
  • Foleys catheter
  • confirm placenta and membranes complete
  • 500 micrograms ergometrine IV (avoid if cardiac disease/hypertension)
  • vaginal/perineal trauma
  • cervical trauma
73
Q

If PPH has not responded to ergometrine, or syntocinon what should be done?

A
  • caboprost/haemabate (PGF2a) 250mcg IM every 15 min (max 8 doses)
  • Misoprostol 800mcg PR
  • tranexamic acid 0.5g-1g IV
  • EUA in theatre if still bleeding
  • CALL CONSULTANT
74
Q

How can the bleeding be stopped non-surgically?

A
  • packs and balloons- rusch balloon, bakri balloon
  • tissue sealants
  • interventional radiology: arterial embolisation
75
Q

How can the bleeding be stopped surgically?

A
  • undersuturing
  • brace sutures- B lynch suture
  • uterine artery ligation
  • internal iliac artery ligation
  • hysterectomy
76
Q

Describe fluid replacement in PPH

A
  • 2 large bore IV access
  • rapid fluid resuscitation - crystalloid hartmann’s, 0.9% N/saline
  • blood transfusion early
  • consider O neg if life threatening
  • if DIC/coagulopathy- FFP, cryoprecipitate, platelets
  • use blood warmer
  • cell saver
77
Q

What must be excluded in secondary PPH

A

Retained products of conception with USS

78
Q

What happens after PPH has been managed?

A
  • thromboprophylaxis
  • debrief couple
  • manage anaemia- IV Fe/oral
  • Datix & risk management

Reproductive & Sexual Health (54 decks)

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