bleeding in pregnancy- 2nd and 3rd trimester Flashcards
compare and contrast placenta prevevia and abruption
- both present with vaginal bleeding > 24 weeks
- placenta preveia is painless but abruption is painful
- blood with preveia is bright red but abruption is dark red
- bleeding is not concealed with preveia, but is with abruption
what are signs of abruption?
- dark red bleeding or concealed bleeding
- shock not in keeping with bleeding
- tender ‘woody uterus’
symptoms of placental abruption?
- content lower Abdo pain
- patients often present in labour
how is palcental abruption diagnosed?
- diagnosis is clinical
- other examinations can be used to guide management:
- CTG to assess fetal compromise
- FBC to asses degree of blood loss
- clotting screen because DIC can occur with significant haemorrhage
- group and save, in case they need a transfusion
- VBG because metabolic acidosis may occur with significant haemorrhage
- USS, poorly sensitive but good positive predictive value for haemorrhage
how is placental abruption managed if there is acute bleeding?
- admit to hospital and stabilise patient with fluids, transfusion and possibly TXA
- emergency c-section if there is maternal or fetal compromise
- Anti-D to Rh- mothers
how should placental abruption be managed if there is no fetal or maternal comprimise?
conservative: regular maternal kand fetal monitoring
corticosteroids and tocolytics: if <34 weeks gestation for lung maturation, first line tocolytic is nifedipine
vaginal delivery: >34 weeks- if no contractions present consider induction
Anti-D given to rh- mothers
what is the management if the foetus has died due to placental abruption?
- vaginal delivery if mother is stable and if not then C Section
- Anti-D should be given
what are the risks of abruption to the the mother?
- massive haemorrhage
- DIC
what are risks of abruption to the foetus?
- preterm birth
- death-> 50% of cases of abruption
what are the 4 grades of placenta praevia?
Grade I: low-lying placenta; placenta in the lower segment (< 20 mm from the internal cervical os), but does not cover it
Grade II: marginal praevia; placenta reaches the margin of the internal cervical os, but does not cover it
Grade III: partial praevia; placenta partially covers the internal cervical os
Grade IV: complete praevia; placenta completely covers the internal cervical os
what are risk factors for placenta praaevia?
Previous caesarean section: causes uterine scarring, resulting in an adherent placenta Increasing parity Increasing maternal age Smoking Previous miscarriage Previous abortion Cocaine use
what is on thing that should be avoided with placenta previa?
Avoid bimanual examination until the placental position has been confirmed.
what are the next steps if a low lying placenta is found on the 20 week anomaly scan?
If low-lying on routine anomaly scan: perform a
transvaginal ultrasound (TVUS) at 32 weeks to recheck the position; if persistent, perform another TVUS at 36 weeks to guide delivery
which investigations should be performed for a woman presenting acutely with suspected placenta previa?
If the patient presents acutely and placental position is unknown: perform an urgent TVUS
Special investigations [1]:
Foetal cardiotocography (CTG): if the patient presents acutely with blood loss, CTG should be monitored to assess for foetal compromise
Bloods [1]:
FBC: assess the degree of blood loss if the patient presents with bleeding
Clotting screen: disseminated intravascular coagulation can occur in significant haemorrhage
Crossmatch: perform if considering transfusion in a bleeding patient
Venous blood gas: metabolic, lactic acidosis may be present with significant bleeding
what is the management for placenta praevia if there is no bleeding?
Planned caesarian section: aim for delivery between 36+0 and 37+0 weeks of gestation; if there has also been a history of vaginal bleeding, late preterm (34+0 - 36+6) delivery should be considered
Anti-D immunoglobulin: given if rhesus negative
what is the management for placenta previa if there is active bleeding?
Resuscitation: admit to hospital and stabilise the patient with fluids, +/- transfusion, +/- tranexamic acid
Emergency caesarean section: indicated if there is a risk of immediate maternal or foetal compromise. However, if the patient is stable, they can be admitted under specialist care
Anti-D immunoglobulin: given if rhesus negative
what is the prognosis for placenta previa?
85% of cases of placenta praevia in early pregnancy (15-19 weeks) will no longer be praevia at labour as the placenta migrates
In general, both foetal and maternal prognosis is good.
what are the clinical features of GTD?
- hyperemesis
- vaginal bleeding
- grape-like masses in the vagininal passage
- uterus large for dates
- BHCG mimics TSH and can cause; tachycardia, tremor, sweating and hypertension
when does GTD usually present?
- first trimester
in which type of GTD are the symptoms more severe?
complete molar pregnancy
what are risk factors for GTD?
Extremes of reproductive age: < 16 years or > 45 years
Prior gestational trophoblastic disorder
Family history
what is the pathophysiology of a complete mole?
- haploid sperm fertilises an empty egg leading to trophoblastic proliferation of the hydronic villi
- the risk of gestational trophoblastic neoplasia as a result of this is 20%
what is the pathophysiology of a partial mole?
- two sperm fertilise a normal egg
- end up with 69 chromosomes
- fetal tissues are present
- there is a 5% risk of trophoblastic neoplasia
what are the different types of gestational trophoblastic neoplasia?
- invasive mole
2. choriocarcinoma- has worse outcome and is associated with widespread metastasis, including the lungs and brain
what is the management of a molar pregnancy?
Suction curettage: the preferred method of evacuation for both complete and partial moles. All samples should be sent for histology to exclude neoplasia
Anti-D prophylaxis: required for patients following evacuation
β-hCG is monitored regularly post-evacuation until it has normalised; failure to normalise suggests recurrence
what is the management of gestational trophoblastic neoplasia?
Chemotherapy: intramuscular methotrexate alone (low-risk) or with other agents, such as dactinomycin (high-risk or metastatic)
Management is based on the FIGO 2000 scoring system-> higher risk patients may be treated with combined therapy
what are complications of GTD?
Malignant transformation: benign moles may transform into gestational trophoblastic neoplasia (invasive mole or choriocarcinoma). The lungs are the most common site of metastasis
Asherman’s syndrome: secondary to curettage which causes uterine adhesions, potentially resulting in amenorrhoea
Pre-eclampsia: may reflect advanced diseas
what are the main risk factors for placenta accreta?
previous caesarean section
placenta praevia
