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Bleeding in Late Pregnancy Flashcards

1
Q

What are some features of the placenta?

A

Entirely foetal tissue
Sole source of foetal nutrition from 6 weeks
Functions = gas transfer, metabolism, hormone production

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2
Q

What is antepartum haemorrhage defined as?

A

Bleeding from the genital tract after 24 weeks gestation and before the end of second stage of labour

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3
Q

How common is antepartum haemorrhage?

A

Complicates 3-5% of pregnancy = associated with 1/5 of preterm babies

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4
Q

What are some causes of antepartum haemorrhage?

A

Placental abruption, placenta praevia, placenta accreta

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5
Q

What are the differentials of antepartum haemorrhage?

A

Heavy show, cystitis, haemorrhoids

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6
Q

How is antepartum haemorrhage quantified?

A 
Spotting = staining, streaking
Minor = <50ml
Major = 50-1000ml, no shock
Massive = >1000ml and/or shock
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7
Q

What is placental abruption?

A

Separation of a normally implanted placenta before birth of foetus = 70% occur in low risk pregnancies

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8
Q

How common is placental abruption?

A

Accounts for 40% of antepartum haemorrhage

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9
Q

How does placental abruption leads to hypoxia and Couvelaire uterus?

A

Vasospasm followed by arteriole rupture into decidua and blood escapes into amniotic sac/myometrium = causes tonic contraction and interrupts placental circulation

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10
Q

What are the risk factors for placental abruption?

A

Pre-eclampsia, trauma, smoking, cocaine, diabetes, renal disease, thrombophilia, polyhydramnios, multiple pregnancy, abnormal placenta, previous abruption

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11
Q

What are the symptoms of placental abruption?

A

Continuous severe abdominal pain, backache if posterior placenta, bleeding, preterm labour, collapse

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12
Q

What are the features of an abdominal examination of someone with placental abruption?

A

Uterus LFO/normal, uterine tenderness, woody hard uterus, foetal parts hard to identify, preterm labour with heavy show

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13
Q

What is the foetal condition in placental abruption?

A

Bradycardia or absent heart rate

CTG shows irritable uterus = 1 contraction/min, tachycardia, loss of variability, decelerations

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14
Q

How do you resuscitate the mother after a massive bleed?

A

Rapid assessment and delivery
2 large bore IV access and IV fluids
Xmatch 4-6 units haemoglobin
Catheterise and do bloods (FBC, clotting)

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15
Q

What is the management of placental abruption?

A

Assess foetal heart = CTG, USS if no rate detected

Delivery = urgent C-section, induction of labour by amniotomy

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16
Q

What are the maternal complications of placental abruption?

A

Hypovolaemic shock, anaemia, postpartum haemorrhage (25%), renal failure, coagulopathy, infection, thromboembolism

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17
Q

What are the foetal complications of placental abruption?

A

Death (14%), hypoxia, prematurity, small for gestational age, foetal growth restriction

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18
Q

What is the rate of recurrence for placental abruption?

A

10%

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19
Q

What should be given to women with antiphospholipid syndrome as prophylaxis for placental abruption?

A

LMWH and low dose aspirin

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20
Q

What does placenta praevia refer to?

A

Placenta lies directly over internal os

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21
Q

What does the term low lying placenta refer to?

A

When placental edge is <20mm from internal os on scanning after 16 weeks gestation

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22
Q

What is the lower segment of the uterus defined as anatomically?

A

Part of the uterus below utero-vesical peritoneal pouch superiorly and internal os inferiorly

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23
Q

What is the lower segment of the uterus defined as physiologically?

A

Part of uterus which doesn’t contract in labour but passively dilates

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24
Q

What is the lower part of the uterus defined as metrically?

A

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

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25
Q

How common is placenta praevia?

A

20% of antepartum haemorrhages

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26
Q

What are the risk factor for placenta praevia?

A

Previous C-section, previous abortion, age >40, multiparity, assisted conception, multiple pregnancy, smoking, deficient endometrium

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27
Q

How is placenta praevia screened for?

A

20 week foetal anomaly scan should include placental location = rescan at 32 weeks and 36 weeks if persistent low position

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28
Q

What type of scan is preferred for assessing placental location?

A

Transvaginal

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29
Q

When should cervical length be assessed?

A

Before 34 weeks gestation = assesses risk of preterm labour

30
Q

What investigation should be done is placenta accreta is suspected?

A

MRI

31
Q

What are the symptoms of placenta praevia?

A

Painless bleeding >24 weeks = may be triggered by sex

Foetal movements usually present

32
Q

What are the features of an abdominal examination in placenta praevia?

A

Uterus soft and non-tender, presenting part high, malpositions

33
Q

What is the CTG like in placenta praevia?

A

Usually normal = do from 28 weeks

34
Q

What examination shouldn’t be done until placenta praevia is ruled out?

A

Vaginal examination

35
Q

How is placenta praevia diagnosed?

A

Check anomaly scan and confirm by transvaginal US

36
Q

What is the management for placenta praevia that is actively bleeding?

A

Admit for at least 24hrs until bleeding stops
Anti-D if Rhesus negative, prevent and treat anaemia
Antenatal corticosteroids between 24-35+6 weeks
TEDS = no fragmin unless prolonged stay

37
Q

What is the management of placenta praevia when there is no bleeding?

A

Advise patient no sex and attend if there is bleeding (including spotting) or contractions/pain

38
Q

When would you consider delivery in placenta praevia?

A

34-36 weeks if history of PVB or other risk factors for preterm delivery
36-37 weeks if uncomplicated

39
Q

What type of delivery can be done in a woman with placenta praevia?

A

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

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

40
Q

What are some features of a C-section for placenta praevia?

A

Cell salvage and aim to avoid cutting through placenta

Skin and uterine incisions vertical <28 weeks if transverse lie

41
Q

What is placenta accreta?

A

Morbidly adherent placenta = abnormally adherent to uterine wall

42
Q

How common is placenta accreta?

A

5-10% of placenta praevia

43
Q

What is placenta accreta associated with?

A

Severe bleeding, postpartum haemorrhage and hysterectomy

44
Q

What are the risk factors for placenta accreta?

A

Placenta praevia, previous C-sections

45
Q

What are the different types of placenta accreta?

A

Placenta increta = invading myometrium

Placenta percreta = penetrating uterus to bladder

46
Q

What is the management of placenta accreta?

A

Prophylactic internal iliac artery balloon
Caesarean hysterectomy
Expect blood loss >3L

47
Q

What is uterine rupture?

A

Full thickness opening of the uterus including serosa

Termed dehiscence if serosa intact

48
Q

What are the risk factors for uterine rupture?

A

Previous C-section or uterine surgery, multiparity, use of prostaglandins, obstructed labour

49
Q

What are the symptoms of uterine rupture?

A

Severe abdominal pain, shoulder tip pain, maternal collapse, PV bleeding

50
Q

What are the signs of uterine rupture?

A

Loss of contractions, acute abdomen, PP rises, peritonism, foetal distress

51
Q

What is the management of uterine rupture?

A

Urgent resuscitation and surgical management

52
Q

What is vasa praevia?

A

Unprotected foetal vessels traverse membranes below presenting part over internal cervical os = rupture during labour

53
Q

How is vasa praevia diagnosed?

A

US with doppler

54
Q

How does vasa praevia present?

A

ARM and sudden dark red bleeding with foetal bradycardia or death

55
Q

What are the types of vasa praevia?

A 
1 = vessels connected to velamentous umbilical cord
2 = vessels connect placenta with succenturiate or accessory lobes
56
Q

What are the risk factors for vasa praevia?

A

Placental anomalies (e.g bilobed placenta), history of low lying placenta in 2nd trimester, multiple pregnancy, IVF

57
Q

What is the management for vasa praevia?

A

Steroids from 32 weeks
In-patient management if risks of preterm birth
Elective C-section at 34-36 weeks

58
Q

When would you do an emergency C-section for vasa praevia?

A

If antepartum haemorrhage occurs

59
Q

What is post partum haemorrhage defined as?

A

Blood loss >=500ml after delivery

60
Q

How is postpartum haemorrhage classed?

A 
Primary = within 24hrs of delivery
Secondary = >24hrs - 6 weeks post delivery 
Minor = 500-1000ml without shock
Major = >1000ml or signs of CV collapse or ongoing bleeding
61
Q

What are the causes of postpartum haemorrhage?

A

Tone (70%), trauma (20%), tissue (10%), thrombin (<1%)

62
Q

What are the antenatal risk factors for postpartum haemorrhage?

A

Anaemia, previous C-section, placenta praevia/accreta, previous PPH, previous retained placenta, multiple pregnancy, polyhydramnios, obesity, macrosomia

63
Q

What are the intrapartum risk factors for postpartum haemorrhage?

A

Prolonged labour, C-section, retained placenta, operative vaginal delivery

64
Q

What is the active management for the third stage of labour?

A

IM or IV syntocinon/syntometrine

65
Q

What is the management of of minor postpartum haemorrhage?

A

IV access and IV warmed crystalloid infusion
G & S, FBC and coagulation
Pulse, BP and resp rate taken every 15 mins

66
Q

What are some ways to stop the bleeding in postpartum haemorrhage?

A

Bimanual uterine compression, expel clots, 5 units IV syntocinon, syntocinon in 500ml Hartmann’s, Foley’s catheter, 500mg ergometrine, misoprostol 800mcg, tranexamic acid 0.5-1g IV

67
Q

How should persistent postpartum haemorrhage be managed?

A

EUA in theatre

68
Q

What are non-invasive treatments for postpartum haemorrhage?

A

Packs and balloons = Rusch or Bakri balloons

Tissue sealants or interventional radiology

69
Q

What are the surgical treatments for postpartum haemorrhage?

A

Undersuturing, B-Lynch suture, uterine artery ligation, internal iliac artery ligation, hysterectomy

70
Q

How are fluids replaced in postpartum haemorrhage?

A

2 large bore IV access and blood transfusion early
Crystalloid Hartmann’s and 0.9% sodium saline
Cell saver, blood saver and consider O- if severe
If DIC/coagulopathy = FFP, cryoprecipitate, platelets

71
Q

How should secondary postpartum haemorrhage be managed?

A

Exclude RPOC with US

Infection likely to play a role

72
Q

What three things are essential to the treatment of antepartum haemorrhage?

A

Kleihauer = measures amount of foetal Hb transferred to maternal circulation
Anti-D and steroids

Reproduction (62 decks)

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