bleeding in pregnancy- 2nd and 3rd trimester

Question 1

compare and contrast placenta prevevia and abruption

Answer 1

• 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

Question 2

what are signs of abruption?

Answer 2

• dark red bleeding or concealed bleeding
• shock not in keeping with bleeding
• tender ‘woody uterus’

Question 3

symptoms of placental abruption?

Answer 3

• content lower Abdo pain

- patients often present in labour

Question 4

how is palcental abruption diagnosed?

Answer 4

• 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

Question 5

how is placental abruption managed if there is acute bleeding?

Answer 5

• 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

Question 6

how should placental abruption be managed if there is no fetal or maternal comprimise?

Answer 6

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

Question 7

what is the management if the foetus has died due to placental abruption?

Answer 7

• vaginal delivery if mother is stable and if not then C Section
• Anti-D should be given

Question 8

what are the risks of abruption to the the mother?

Answer 8

• massive haemorrhage

- DIC

Question 9

what are risks of abruption to the foetus?

Answer 9

• preterm birth

- death-> 50% of cases of abruption

Question 10

what are the 4 grades of placenta praevia?

Answer 10

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

Question 11

what are risk factors for placenta praaevia?

Answer 11

Previous caesarean section: causes uterine scarring, resulting in an adherent placenta
Increasing parity
Increasing maternal age
Smoking
Previous miscarriage
Previous abortion
Cocaine use

Question 12

what is on thing that should be avoided with placenta previa?

Answer 12

Avoid bimanual examination until the placental position has been confirmed.

Question 13

what are the next steps if a low lying placenta is found on the 20 week anomaly scan?

Answer 13

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

Question 14

which investigations should be performed for a woman presenting acutely with suspected placenta previa?

Answer 14

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

Question 15

what is the management for placenta praevia if there is no bleeding?

Answer 15

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

Question 16

what is the management for placenta previa if there is active bleeding?

Answer 16

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

Question 17

what is the prognosis for placenta previa?

Answer 17

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.

Question 18

what are the clinical features of GTD?

Answer 18

• 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

Question 19

when does GTD usually present?

Answer 19

• first trimester

Question 20

in which type of GTD are the symptoms more severe?

Answer 20

complete molar pregnancy

Question 21

what are risk factors for GTD?

Answer 21

Extremes of reproductive age: < 16 years or > 45 years
Prior gestational trophoblastic disorder
Family history

Question 22

what is the pathophysiology of a complete mole?

Answer 22

• 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%

Question 23

what is the pathophysiology of a partial mole?

Answer 23

• two sperm fertilise a normal egg
• end up with 69 chromosomes
• fetal tissues are present
• there is a 5% risk of trophoblastic neoplasia

Question 24

what are the different types of gestational trophoblastic neoplasia?

Answer 24

1. invasive mole

2. choriocarcinoma- has worse outcome and is associated with widespread metastasis, including the lungs and brain

Question 25

what is the management of a molar pregnancy?

Answer 25

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

Question 26

what is the management of gestational trophoblastic neoplasia?

Answer 26

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

Question 27

what are complications of GTD?

Answer 27

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

Question 28

what are the main risk factors for placenta accreta?

Answer 28

previous caesarean section

placenta praevia