Bleeding in Late Pregnancy Flashcards
Define antepartum haemorrhage
Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
What are the key functions of the placenta?
- gas transfer
- metabolism/waste disposal
- hormone production (HPL, hGhV)
- protective filter
What can cause antepartum haemorrhage?
Placental problem - praeiva/abruption Uterine problem - rupture Local causes - ectropion, polyps, infection, carcinoma Vasa praevia Indeterminate
State the differential diagnosis of antepartum haemorrhage
Heavy show, cystitis, haemorrhoids
Describe the classifications of antepartum haemorrhage
Spotting - staining, streaking, wiping
Minor - <50ml settled
Major - 50-100ml no shock
Massive - >1000ml +/- shock
Define placental abruption
Separation of a normally implanted placenta can occur partially or totally before birth of the foetus
Describe the pathology behind placental abruption
Vasospasm followed by arteriole rupture into the decidua, blood escapes into the amniotic sac or further under the placenta and into the myometrium
Tonic contraction and interrupts placental circulation causing hypoxia
What is meant by couvelaire uterus?
Haematoma bruised uterus, that does not contract
State the risk factors for placental abruption
70% unknown, low risk pregnancies Pre-eclampsia Trauma Smoking/drugs Medical conditions - renal, thyroid, diabetes, coagulopathy Polyhydramios Abnormal placenta PROM Previous abruption
What are the symptoms of placental abruption?
Severe continuous abdominal pain, backache if posterior placenta, bleeding, pre-term labour
What are the signs of placental abruption?
Very unwell patient, uterus may be large, tender and woody hard
What is meant by woody hard uterus?
Unable to identify fetal parts
Describe the fetal signs of placental abruption
Fetal distress - bradycardia/absent heart beat/tachycardia
CTG - irritable uterus, loss of variability, decelerations, tachycardia
What does a CTG of an irritable uterus show?
1 contraction/minute
How do you resusciate a mother?
2 large bore IV access, bloods - FBC, clotting, LFT, U and E, crossmatch 4-6 units, Kleihaur
IV fluids, catheterise and urometer
How is placental abruption managed?
Minor - expectant, allow steroid cover
Mild - induce labour by amniotomy
Major - C-section
What are the maternal complications of placental abruption?
Hypovolaemic shock Anaemia PPH Renal failure due to tubular necrosis DIC, coagulopathy Infection Complications of blood transfusion Thromboembolism
What are the fetal complications of placental abruption?
IUD Hypoxia Preterm (iatrogenic/spontaneous) Small baby Fetal growth restriction
How can placental abruption be prevented?
Anti-phospholipid Syndrome management Drug misuse Smoker Folic Acid Screen for domestic violence
Define placenta praevia
Placenta lies directly over the internal os
Define low lying placenta
After 16/40 when the placental edge is less than 20mm from the internal os on ultrasound
What is special about the lower uterus?
Below the utero-vesical peritoneal pouch superiorly and the internal os inferiorly it contains less muscle fibres and does not contract instead passively dilates
7cm from the internal os
State the risk factors for placental praevia
Previous c-section Previous TOP Advanced maternal age >40 Multiparity/multiple pregnancy Assisted conception Smoking
What can make a uterus deficient?
Presence of uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid
How is placenta praevia screening for and diagnosed?
Midtrimester fetal anomaly scan includes placenta localisation - rescan at 32 and 36 weeks if persistent
Transvaginal scan
Assess cervical length <34 weeks if risk of preterm labour
State the symptoms of placenta praevia
Painless bleeding >24 weeks, may be triggered by coitus, can be minor and fetal movements usually present
What are the signs of placental praevia?
Uterus soft non tending with high presenting part commonly malpresenations with normal CTG
What must not be done in placenta praevia?
Digital examination
How is placenta praevia managed?
ABCDE Assess baby Resus - admit for at least 24 hours TED stockings No sex Delivery plan and magnesium sulphate
If a woman has placenta praevia and is bleeding describe the management
Resus Major haemorrhage protocol IV fluids and transfuse Anti-D Monitor fetal heart on CTG Steroids 24-36weeks Magnesium sulphate Deliver if active bleeding
Describe delivery options in placenta praevia
C-section; if placenta covers os or <2cm from cervical os Vaginal if placenta >2cm from os and no malpresentation
What do you need to consent for in C section?
General anaesthetic
Hysterectomy
Cell salvage
Vertical incision
Define placenta accreta
Morbidly adherent placenta - abnormally adherent to the uterine wall
What are the risk factors for placenta accreta?
Previous c section, placenta praevia
Name the two grades of placenta accreta
Invading myometrium - increta
Penetrating uterus to bladder - percreta
How is placenta accreta managed?
Prophylactic internal iliac artery balloon
Caesarean hysterectomy
Blood loss >3l expected
Conservative management and methotrexate - deliver baby and abode placenta by cutting upper segment of uterus
What is meant by uterine rupture?
Full thickness opening of uterus including the serosa
What is a rupture called when the serosa is intact?
Dehinscence
State the risk factors for uterine rupture
Previous c-section/uterine surgery, multiparity, use of prostaglandins/syntocinon, obstructed labour
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 Presenting part rises Peritonism Fetal distress/IUD
How is uterine rupture managed?
Resus and surgery
Define vasa praevia
Unprotected fetal vessels transversing the membrane below the presenting part over the internal os - will rupture during labour/amniotomy
How is vasa praevia diagnosed?
Ultrasound TA or TV with doppler
Clinically - sudden dark red bleeding and fetal distress
Name the two types of vasa praevia
type 1 - vessel is connected to a velamentous umbilical cord
type 2 - vessel connects the placenta with succenturiate/accessory lobe
What are the risk factors for vasa praevia?
Placental anomalies
History of low lying placenta in second trimester
Multiple pregnancy
IVF
How is vasa praevia managed?
Steroids
Elective C-section 34-36 weeks if detected
APH - emergency c-section
Define post partum haemorrhage
Blood loss >500ml after the birth of the baby
What are the two types of PPH?
Primary - within 24 hours of birth
Secondary - >24 hours to 6 weeks post delivery
What are the two classifications of PPH?
Minor - 500ml-1000ml without shock
Major - >1000ml or signs of CV collapse/on-going bleeding
State the four Ts of PPH
Tone
Trauma
Tissue
Thrombin
What are the antenatal risk of PPH?
Anaemia, C-section, placenta problems, previous PPH, multiple pregnancy, obesity, polyhydramios, fetal macrosomia
What are the intrapartum risk of PPH?
Prolonged labour, operative delivery, C-section, retained placenta
What is given in stage 3 to prevent PPH?
Syntocinon and syntometrine IM/IV
State the three key steps in managing PPH
- Assess
- Stop Bleeding
- Fluid Replacement
Describe the assess part of PPH management
Vital signs - pulse, BP, cap refill, stats every 15 mins
Oxygen high flow 6l/min
Determine cause
Blood samples - FBC, clotting, fibrinogen, U/E, LFT, lactate, cross match 6 units
How is fluid replacement in PPH carried out?
2 large bore IV access - rapid fluid resuscitation with crystalloid, hartmann’s or 0.9% saline
Blood transfusion and warming
DIC/coagulopathy
Cell saver
What is tried first to stop the PPH bleeding?
Uterine massage/bimanual compression Expel clots IV stat - 5 units syntocinon Infusion 40 units syntocinon in 500ml Hartmann's Foleys Catheter with hourly volumes
If step one fails what is done next?
Ergometrine Carboprost/haemabate Misoprostol Tranexamic Acid Examination under anaesthetic
Name three non-surgical techniques to stop PPH
Packs and balloons (Bakri or Rusch)
Tissue sealants
Interventional radiology (arterial embolisation)
Name the surgical techniques to stop PPH
Understuturing, brace sutures, uterine artery ligation, internal iliac artery ligation, hysterectomy
What is required post delivery and PPH?
Thromboprophylaxis, debrief couple, manage anaemia
