Bleeding in Late Pregnancy Flashcards
What is the definition of bleeding in early pregnancy?
<24 weeks
What is the definition of bleeding in late pregnancy?
Antepartum haemorrhage - UK >/= 24 weeks
When does the placenta become the foetus’ main source of nutrition?
From 6 weeks
What are the functions of the placenta?
- Gas transfer
- Metabolism/waste disposal
- Hormone production (HPL & hGh-V)
- Protective ‘filter’
What is the definition of antepartum haemorrhage?
- 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
What are the commonest causes of APH?
Placental abruption and placenta praevia
What is the aetiology of APH?
- Placental problem
- praevia
- abruption
- Uterine problem
- rupture
- indeterminate
- vasa praevia
- local causes
- infection
- ectropion
- polyp
- carcinoma
What is the DDx of APH?
- Heavy show
- Cystitis
- Haemorrhoids
What is spotting
Blood staining, streaking or on wiping
What is minor APH?
<50ml settled
What is major APH?
50-1000ml no shock
What is massive APH?
>1000ml and/or shock
What is placental abruption?
Separation of a normally implanted placenta- partially or totally before birth of the foetus
CLINICAL DIAGNOSIS
Placental abruption occurs in _% of pregnancies
Placental abruption occurs in __% of APH
Placental abruption occurs in 1% of pregnancies
Placental abruption occurs in 40% of APH
What is the pathophysiology of placental abruption?
- 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
What are the risk factors for placental abruption
- 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
What are the symptoms of placental abruption?
- severe continuous abdominal pain
- backache with posterior placenta
- bleeding (may be concealed)
- preterm labour
- maternal collapse
What are the abdominal signs of placental abruption?
- uterus LFD or normal
- uterine tenderness
- woody hard uterus
- fetal parts difficult to identify
- may be in preterm labour (with heavy show)
What are the signs of placental abruption in the foetus?
- fetal heart rate: bradycardia/absent (intrauterine death)
- CTG shows irritable uterus
- 1 contraction/minute
- FH abnormality- tachycardia, loss of variablility, decelerations
Describe the management of placental abruption
- resuscitate mother
- assess & deliver the baby
- manage the complications
- debrief the parents
Describe resuscitation of mother in placental abruption
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
What are the maternal complications of placental abruption?
- 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
What are the foetal complications with Placental abruption?
- IUD (14%)
- hypoxia
- prematurity- iatrogenic & spontaenous
- small for gestational age and foetal growth restriction
What is the treatment of anti-phospholipid syndrome causing placental abruption?
LMWH & LDA
What is placenta praevia
When the placental lies directly over the internal os
What is low-lying placenta
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
What is the anatomical lower segment of the uterus?
- 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
What is the physiological lower segment of the uterus?
The part of the uterus which does not contract in labour but passively dilates
What is the metric lower part of the uterus?
The part of the uterus which is about 7cm from the level of the internal os
Placenta praevia is present in __% of APH
20
_________ delivery is associated with an increased risk of placenta praevia in subsequent pregnancies
Caesarean delivery is associated with an increased risk of placenta praevia in subsequent pregnancies
What are the risk factors for placenta praevia?
- 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
How is placenta praevia screened for?
- 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
What are the symptoms of placenta praevia?
- painless bleeding
- usually unprovoked but coitus can trigger bleeding
- bleeding can be minor e.g. spotting/severe
- foetal movements usually present
What are the signs of placenta praevia?
- general
- proportional symptoms to amount of bleeding
- abdomen
- uterus soft non-tender
- presenting part high
- malpresentations- breech/transverse/oblique
- fetal heart
- CTG usually normal
When can vaginal examination be performed if placenta praevia suspected?
Only after it is excluded
How is placenta praevia diagnosed?
- CHECK anomaly scan
- confirm by TVUS
- MRI for excluding placenta accreta
How is placenta praevia managed?
- 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)
When should patients attend immediately (previous diagnosis of placenta praevia)?
Any bleeding including spotting
Contractions or pain
What can patients with placenta praevia not do
have sex
When should delivery be considered in placenta praevia?
- 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
What is the management of a bleeding mother with placenta praevia?
- 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
How can delivery be planned in placenta praevia?
- C/section : if placenta covers os or <2cm from cervical os
- Vaginal delivery if placenta >2cm from os and no malpresentation
Describe c/section planning in placenta praevia?
- 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
What is placenta accreta?
A morbidly adherent placenta: abnormally adherent to the uterine wall
What increases the risk of placenta accreta?
Multiple c/sections
What is placenta accreta associated with?
Severe bleeding, PPH and may end up having hysterectomy
What is increta?
Invasion of myometrium
What is percreta?
Penetrating uterus to bladder
Describe the management of placenta accreta?
- Prophylactic internal iliac artery balloon
- Caesarean hysterectomy
- Blood loss >3L expected
- Conservative Management (?plus Methotrexate)
What increases the risk of uterine rupture
- previous c/sections
- IOL
- previous rupture
Define uterine rupture?
Full thickness opening of uterus
Including serosa
If serosa is intact- dehiscence
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
- PP rises
- loss of uterine contractions
- peritonism
- fetal distress/IUD
what is the management of uterine rupture?
- 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)
Define vasa praevia
- unprotected fetal vessels transverse the membranes below the presenting part over the cervical os
What is the problem with vasa praevia?
Will rupture during labour or at amniotomy
How is vasa praevia diagnosed?
US TA & TV with doppler
Clinical- ARM and sudden dark red bleeding, fetal bradycardia/death
What is type I vasa praevia?
When the vessel is connected to a velamentous umbilical cord
What is type II vasa praevia?
When it connects the placenta with a succenturiate or accessory lobe
What are the risk factors for placenta praevia?
- 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
What is the management of vasa praevia?
- 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
Define post-partum haemorrhage?
blood loss equal to or exceeding 500ml after the birth of the baby
Define primary and secondary PPH
- Primary
- within 24hr of delivery
- secondary
- >24h-6/52 post delivery
Define minor and major PPH
- minor
- 500-1000ml (without clinical shock)
- major
- >1000ml or other signs of CV collapse or on-going bleed
What are the 4 T’s?
Causes of PPH
- tone 70%
- trauma 20%
- tissue 10%
- thrombin <1%
What are the risk factors for PPH
- anaemia
- previous c/s
- placenta praevia, percreta, accreta
- previous PPH
- previous retained placenta
- multiple pregnancy
- polyhydramnios
- obesity
- foetal macrosomia
What are the intrapartum risk factors for PPH
- prolonged labour
- operative vaginal delivery
- caesarean section
- retained placenta
- active managment of third stage
- syntocinon/syntometrine IM/IV
What is the initial management of PPH
- call for helo
- assess
- stop bleeding
- fluid replacement
Describe management of minor PPH
- 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
What is assessed in PPH
- 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
How can the bleeding be stopped in PPH?
- 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
If PPH has not responded to ergometrine, or syntocinon what should be done?
- 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
How can the bleeding be stopped non-surgically?
- packs and balloons- rusch balloon, bakri balloon
- tissue sealants
- interventional radiology: arterial embolisation
How can the bleeding be stopped surgically?
- undersuturing
- brace sutures- B lynch suture
- uterine artery ligation
- internal iliac artery ligation
- hysterectomy
Describe fluid replacement 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
- if DIC/coagulopathy- FFP, cryoprecipitate, platelets
- use blood warmer
- cell saver
What must be excluded in secondary PPH
Retained products of conception with USS
What happens after PPH has been managed?
- thromboprophylaxis
- debrief couple
- manage anaemia- IV Fe/oral
- Datix & risk management
