Bleeding In Pregnancy Flashcards
Most common cause of maternal mortality?
Genital tract sepsis
Second most common cause of maternal mortality?
Haemorrhage
What are the causes of early pregnancy haemorrhage?
Miscarriage
Ectopic pregnancy
What are the causes of late pregnancy and labour haemorrhage?
Placental abruption
Placenta praevia
Ruptured uterus
What are the causes of post-partum haemorrhage?
Uterine atony
Trauma
Retained placenta / products
Ruptured uterus
What are the different types of miscarriage?
Missed
Threatened
Inevitable
Complete
Septic
List and describe the methods of managing miscarriage
Expectant (conservative) = most spontaneously resolve
Medical = Mifepristone + Prostaglandin (Misoprostol) + Anti-D prophylaxis
Surgical = If maternal choice or unstable vital signs
What are the risks of surgical treatment of miscarriage?
Cervical injury
Uterine perforation
Infection
Excessive bleeding
What are the symptoms of ectopic pregnancy?
Pain
Bleeding
Faint/collapse
Where can ectopic pregnancies present?
Tubal = 95-96%
Ovarian = 3%
Cervical = 1%
Abdominal = 1%
Caesarian scar
What should be done in the assessment of ectopic pregnancy?
Cervical Examination
Ultrasound
Serial beta-hCG
Describe the management of ectopic pregnancy
Conservative
Medical = methotrexate
Surgical = laprascopy/laparotomy
What is a molar pregnancy?
A gestational trophoblastic disease that grows into a mass in the uterus that has swollen chorionic villi
- Complete vs. Partial mole
What are the features of a molar pregnancy?
USS appearance unique
Large-for-date, Very high hCG, Biochem, Hyperthyroid, Hyperemesis
How should molar pregnancy be treated?
Suction evacuation is indicated
Rarely may need a hysterectomy
Methotrexate if developed into choriocarcinoma
What are the signs of haemorrhage?
Pale Confused Reduced urine output Foetal heart abnormalities Increased Heart Rate Bleeding - obvious/hidden
What is the difference between a revealed and concealed placental abruption?
Revealed = blood tracks between the membranes and escapes through the vagina and cervix
Concealed = blood collects behind the placenta, with no evidence of vaginal bleeding
What are the clinical features of placental abruption?
Vaginal bleeding Abdominal pain Irritable uterus "woody hard" Uterine tenderness Disproportionate shock Foetal distress
What are the clinical features of placental praevia?
Asymptomatic
Painless - bright red blood
Malpresentation/high presenting part
Ultrasound scan fairly obvious
What are the risk factors for placenta praevia?
Previous Hx of praevia Previous lower segment C-section Smoking Older mother Defective endometrium Previous TOP Assisted conception
What is placenta praevia?
A condition in which the placenta partially or wholly blocks the neck of the uterus, so interfering with normal delivery of a baby.
What are the risk factors for placental abruption?
Smoking/drug abuse 1st trimester bleeding Pre-eclampsia Multiparity Blunt force trauma Assisted conception Low BMI
What is placenta accreta, increta and percreta?
Acreta = Firmly adherent placenta
Increta = invades the myometrium
Percreta = invades the serosa and beyond
- cue to blood vessels and other placental parts growing deep into the uterine wall
What in vasa praevia?
Placental vessels overlie the cervix (high mortality)
What is the difference between primary and secondary post-partum haemorrhage?
Primary is less than 24 hours post-delivery
- uterine atony (failure of uterine contraction)
Secondary is greater than 24 hours post-delivery up to 6 weeks post-delivery
- endometritis
What are the risk factors for post-partum haemorrhage?
Pregnancy
- previous PPH
- anti-partum haemorrhage
- placenta praevia
- twins
- nulliparity
- pre-eclampsia/PIH
- Maternal Obesity (BMI > 35)
- Maternal age (>40 years)
Delivery
- emergency LSCS
- repeat elective LSCS
- operative vaginal birth
- induction of labour
- labour lasting > 12 hours
- foetal birthweight > 4 kg
What are the causes of post-partum haemorrhage?
Thrombin (pre-eclampsia, abruption, pyrexia in labour, bleeding disorders)
Tissue (retained placenta/conception products, placenta accreta)
Tone (praevia, uterine over-distension, uterine relaxants, previous PPH)
Trauma (C-section, episiotomy, macrosomia)
How should post-partum haemorrhage be managed?
Stop the bleeding
Laparatomy
Assessment of blood loss
How should bleeding be stopped in PPH?
Tone - empty bladder, “rub up” contraction, bimanual compression, give oxytotics
Trauma - repair tears
Tissue - empty uterus
Thrombin - check coagulation and replace clotting factors and blood products
When would a laparotomy be needed in PPH?
Aortic compression
Uterine haemostatic suture
Arterial ligation
Uterine tamponade
Hysterectomy
Why are signs of hypovolaemia late to develop in blood loss in pregnancy?
Since pregnant women have a larger circulating blood volume to supply foeto-placental unit
- mother shuts off this supply to compensate
May not show signs of shock until about 35% blood loss
