Bleeding in pregnancy Flashcards
1
Q
antepartum haemorrhage
A
Any bleeding from the genital tract after 20 weeks and before the onset of labour
6% of women have bleeding during 3rd trimester
2
Q
causes
A
- Placenta previa
- Placental abruption
- No specific cause
- Other specific causes
- Vasa previa
- Uterine scar disruption
- Vaginal infections
- Post-coital (sex)
- Heavy show
- Vulval varicosities
3
Q
for diagnosis consider…
A
- Colour and consistency of blood loss
- Predisposing factors
- Contractions
- Abdominal/back pain
- DFM
- Lie, presentation and engagement
- Degree of shock
4
Q
placenta previa
A
- Placenta is partially or completely implanted in the lower uterine segment on either the anterior or posterior wall.
- It either completely or partially covers the cervical os or impinges on the edge of the cervical os.
- Low-lying placenta in the second trimester is not uncommon, therefore repeat U/S is indicated at 30-32 weeks for placental localisation.
- Endometrial scarring: previous LSCS, TOP, previous placenta previa (4-8%), closely spaced pregnancies
- Impeded endometrial vascularisation: hypertension, diabetes, drug use, smoking, AMA
- Increased placental mass: multiple pregnancy
- Abnormally shaped uterus: fibroids, bicornuate
5
Q
placenta previa clinical features
A
- Uterus is soft and non tender
- Majority of women present with bright painless bleeding
- 27-32 weeks first bleed common
- Malpresentation or abnormal lie
- Centrally situated placenta have earlier more serve and recurrent bleeds
6
Q
management of bleeding with placenta previa
A
- Obs
- CTG
- Lateral position and gentle palpation
- Weight pads
- IV
- Group and cross match, Kleihauer and steroids if <34 weeks
- USS
7
Q
placenta abruption
A
- Premature separation of a normally implanted placenta
- Maternal haemorrhage occurring in the decidua basalis and causing separation
- Haemhorrage may be concealed, revealed or not, and may present itself as bloody amniotic fluid
- 3-5% pregnancies
8
Q
Conditions associated with placental abruption
A
- Hypertensive disorders
- Previous abruption (10%)
- Trauma
- Smoking
- Amphetamine use
- PROM (5%)
- Twins
- Polyhydramnios
- Lactrogenic
9
Q
clinical features placental abruption
A
- Dark vaginal bleeding
- Abdominal or lower back pain
- Uterine hypertonus
- Uterine contractions:
- ↑frequency and ↓amplitude
- Uterine tenderness
- Fetal lie usually normal
- Fetal distress or fetal death
- Observations may be normal initially
- S/S of hypovolaemia are worse than expected compared to the observed external blood loss
10
Q
management of abruption
A
- Obs
- Palpation
- CTG
- Lateral position
- PV loss monitor
- IV steroids if <34 weeks
- Group and cross match Kleihauer, FBC
- US
11
Q
complications of abruption
A
- Maternal shock
- Anaemia
- Couvelaire uterus
- Infection
- PPH
- DIC: coagulation failure as a result of consumption of clotting factors and/or development of fibrinolysis
- Oliguria, renal failure (rare) due to hypovolaemic shock
- Anterior pituitary necrosis (Sheehan Syndrome)
- Treatment: rapid transfusion with whole blood, FFP and/or platelet transfusion, cryoprecipitate
- Prematurity, fetal distress and fetal death
12
Q
vasa previa
A
- Vasa previa rarely causes third trimester bleeding.
- Occurs when a velamentous insertion of the umbilical cord crosses the cervical os ahead of the presenting part.
- Diagnosis often unknown.
- Usually presents with significant bleeding associated with ROM.
- High perinatal mortality around 60%
13
Q
vasa previa management
A
- Since bleeding is from a fetal source there is danger of fetal exsanguination and death in over 60% of cases if an OT is not in close proximity. NB: blood volume of a term fetus is approximately 250ml.
- If diagnosed prior to labour, elective LSCS is performed and survival rate as high as 97%.
- After ROM fetal distress is profound and disproportionate to the amount of visible blood loss.
- Once vasa previa is confirmed in the presence of a live fetus, LSCS is performed.
14
Q
blood and blood products
A
- Indications: acute, massive haemorrhage, operative complications.
- Types:
- Whole blood: RBC, white cells, platelets and plasma
- Blood fractions: albumin, anti-D.
- Anti D and Rhesus isoimmunisation.
- Refusal issues, personal beliefs,
- Jehovah’s Witness patients.
15
Q
APH SUMMARY
A
- Assessment of general condition.
- General appearance. Signs of shock?
- Vital signs.
- Blood loss: Colour? Amount? Onset?
- History: any predisposing factors?
- Palpation: guarding/tense?
- Assess fetal condition. How?
- NO VE. Speculum and ultrasound to confirm diagnosis.
- Pain relief.
- Reassurance and explanation.
- IV access, group and cross match, Anti D?
- Subsequent management depends on degree of blood loss and maternal and fetal condition.
