Bleeding In Pregnancy

Question 1

Most common cause of maternal mortality?

Answer 1

Genital tract sepsis

Question 2

Second most common cause of maternal mortality?

Answer 2

Haemorrhage

Question 3

What are the causes of early pregnancy haemorrhage?

Answer 3

Miscarriage

Ectopic pregnancy

Question 4

What are the causes of late pregnancy and labour haemorrhage?

Answer 4

Placental abruption

Placenta praevia

Ruptured uterus

Question 5

What are the causes of post-partum haemorrhage?

Answer 5

Uterine atony

Trauma

Retained placenta / products

Ruptured uterus

Question 6

What are the different types of miscarriage?

Answer 6

Missed

Threatened

Inevitable

Complete

Septic

Question 7

List and describe the methods of managing miscarriage

Answer 7

Expectant (conservative) = most spontaneously resolve

Medical = Mifepristone + Prostaglandin (Misoprostol) + Anti-D prophylaxis

Surgical = If maternal choice or unstable vital signs

Question 8

What are the risks of surgical treatment of miscarriage?

Answer 8

Cervical injury

Uterine perforation

Infection

Excessive bleeding

Question 9

What are the symptoms of ectopic pregnancy?

Answer 9

Pain

Bleeding

Faint/collapse

Question 10

Where can ectopic pregnancies present?

Answer 10

Tubal = 95-96%

Ovarian = 3%

Cervical = 1%

Abdominal = 1%

Caesarian scar

Question 11

What should be done in the assessment of ectopic pregnancy?

Answer 11

Cervical Examination

Ultrasound

Serial beta-hCG

Question 12

Describe the management of ectopic pregnancy

Answer 12

Conservative

Medical = methotrexate

Surgical = laprascopy/laparotomy

Question 13

What is a molar pregnancy?

Answer 13

A gestational trophoblastic disease that grows into a mass in the uterus that has swollen chorionic villi

• Complete vs. Partial mole

Question 14

What are the features of a molar pregnancy?

Answer 14

USS appearance unique

Large-for-date, Very high hCG, Biochem, Hyperthyroid, Hyperemesis

Question 15

How should molar pregnancy be treated?

Answer 15

Suction evacuation is indicated

Rarely may need a hysterectomy

Methotrexate if developed into choriocarcinoma

Question 16

What are the signs of haemorrhage?

Answer 16

Pale
Confused
Reduced urine output
Foetal heart abnormalities
Increased Heart Rate
Bleeding - obvious/hidden

Question 17

What is the difference between a revealed and concealed placental abruption?

Answer 17

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

Question 18

What are the clinical features of placental abruption?

Answer 18

Vaginal bleeding
Abdominal pain
Irritable uterus "woody hard"
Uterine tenderness
Disproportionate shock
Foetal distress

Question 19

What are the clinical features of placental praevia?

Answer 19

Asymptomatic
Painless - bright red blood
Malpresentation/high presenting part
Ultrasound scan fairly obvious

Question 20

What are the risk factors for placenta praevia?

Answer 20

Previous Hx of praevia
Previous lower segment C-section
Smoking
Older mother
Defective endometrium
Previous TOP
Assisted conception

Question 21

What is placenta praevia?

Answer 21

A condition in which the placenta partially or wholly blocks the neck of the uterus, so interfering with normal delivery of a baby.

Question 22

What are the risk factors for placental abruption?

Answer 22

Smoking/drug abuse
1st trimester bleeding
Pre-eclampsia
Multiparity
Blunt force trauma
Assisted conception
Low BMI

Question 23

What is placenta accreta, increta and percreta?

Answer 23

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

Question 24

What in vasa praevia?

Answer 24

Placental vessels overlie the cervix (high mortality)

Question 25

What is the difference between primary and secondary post-partum haemorrhage?

Answer 25

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

Question 26

What are the risk factors for post-partum haemorrhage?

Answer 26

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

Question 27

What are the causes of post-partum haemorrhage?

Answer 27

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)

Question 28

How should post-partum haemorrhage be managed?

Answer 28

Stop the bleeding

Laparatomy

Assessment of blood loss

Question 29

How should bleeding be stopped in PPH?

Answer 29

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

Question 30

When would a laparotomy be needed in PPH?

Answer 30

Aortic compression

Uterine haemostatic suture

Arterial ligation

Uterine tamponade

Hysterectomy

Question 31

Why are signs of hypovolaemia late to develop in blood loss in pregnancy?

Answer 31

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