Bleeding in pregnancy Flashcards
What is the definition of antepartum haemorrhage?
bleeding from the genital tract after 20 weeks gestation and before the onset of labour
What is the incidence of antepartum haemorrhage?
affects 2-5% of pregnancy
What are 5 main impacts/risks with antenatal haemorrhage?
- maternal stress
- severe bleeding
- disseminated intravascular coagulation
- fetal neurological damage due to hypoxia
- FDIU/stillbirth/neonatal death
What are the 4 main causes of bleeding in late pregnancy?
- unclassified (47%)
- vasa praevia (0.5%)
- placenta praevia (31%)
- placental abruption (22%)
What are 8 key causes of unclassified or incidental bleeding in pregnancy?
- heavy show/onset of labour
- cervical ectropion
- cervicitis (infection)
- vulvovaginal varicosities
- polyps
- trauma
- haemoturia
- carcinoma
What is Vasa Praevia?
- where blood vessels in the placenta or umbilical cord are trapped betweent the fetus and the cervix
- rare - 0.5% of APH
What is Placenta Praevia?
- where the placenta is partially or wholly implanted in the lower uterine segment
- placenta may begin to separate causing mild to severe usually painless bleeding
- 31% of APH
What is the incidence of placenta praevia?
0.3-0.6% of all pregnancies
What are the 4 main risk factors for placenta praevia?
risk increases with:
- parity
- age
- smoking
- previous C/S
What is the recurrence rate for placenta praevia?
4-8%
What are 10 complications that may be associated with placenta praevia?
- severe blood loss and maternal shock
- anaesthetic and surgical complications
- invasive placenta
- septicemia (infection more likely closer to os)
- thrombosis
- PPH (no oblique muscle fibres in lower segment, decreased action of living ligatures)
- hysterectomy
- renal failure
- maternal death
- fetal hypoxia
What are the four grades of placenta previa?
1 Edge of placenta in lower segment
2 Entire placenta in lower segment
3 Placenta reaches cervical os
4 Placenta covers cervical os
What signs and symptoms may indicate bleeding is due to placenta praevia?
- bright red fresh PV bleeding
- uterus not tender or tense, painless as low placental location allows loss to escape, no retroplacental clot
- potentially unstable fetal lie and high head
- reduced fetal movements due to hypoxia
How is placenta praevia diagnosed?
- confirmed and graded by ultrasound
What is conservative management for placenta praevia?
- appropriate for slight bleeding with well mother/baby
- admission
- strict bed rest
- serial CTG and US
- preparation for birth
What is active management of severe haemorrhage caused by placenta praevia and placental abruption?
- immediate preparation for emergency C/S - support, communication
- IV access 16G cannula
- FBE, group & hold, clotting
- IV infusion/blood transfusion to stabilise
- fetal monitoring
What is placental abruption?
premature separation of a normally located placenta >20 weeks gestation
what is the incidence of placental abruption?
0.5-2% of pregnancies
List 8 risk factors for placental abruption?
- severe preeclampsia
- sudden reduction in uterine size (amnio reduction)
- direct trauma (car accident, violence)
- high parity
- previous C/S
- previous abruption
- smoking
- cocaine use
What is revealed haemorrhage?
- where placenta partially separates around the margin causing bleeding from placental bed which separates membranes from the uterine wall and drains PV
- results in DARK, non clotting PV loss
What is concealed haemorrhage?
- where placenta separates but is unable to escape, so is retained behind placenta and forced into surrounding myometrium
- no PV loss
- signs and symptoms of hypovolaemic shock
- uterine enlargement
- extreme pain
What 8 complications may be associated with placental abruption?
- disseminated intravascular coagulopathy (DIC)
- post partum haemorrhage
- renal failure (hypovolaemia)
- pituitary necrosis (hypotension)
- postnatal anaemia
- 10 times risk in subsequent pregnancies
- perinatal mortality (significant cause of T3 stillbirths)
- maternal mortality & morbidity
Why are signs of shock not always associated with bleeding in pregnancy?
- increased blood volume so signs may not present until 25-30% blood loss
- after fetal circulation has been affected
What assessments are vital where a woman presents with bleeding in pregnancy?
- history (maternal history, gestation, associated with any other event?)
- bleeding (amount, intermittent/continuous)
- ? previous US for placental position
- maternal wellbeing (vital signs, signs of shock)
- fetal wellbeing (fetal movements, ? CTG depending on gestation)
- GENTLE palpation of abdomen (soft/hard, painful, uterine activity, ? lie, presentation, engagement)
- ? medical staff perform speculum (vaginal examination contraindicated)
What management is likely to be necessary if APH but mother and baby are both NOT compromised at 20-24/40, 24-36/40, >36/40?
20-24/40: - unlikely to be placenta praevia - admission - bed rest - monitoring (USS + CTG) - paed consultation 24-36/40: - ? abruption/placenta praevia - ? corticosteroids - Anti-D if Rh -ve - paed consultation >36/40: - ? abruption/placenta praevia - admission - bed rest - monitoring (maternal and fetal) - ? C/S
What management is likely to be necessary if APH with maternal or fetal compromise?
- management depends on condition of mother/baby, degree of haemorrhage, gestation
- ? non-reassuring CTG
- ? signs of maternal compromise
- Call for help (medical staff, senior midwives, anaesthetist, paed, other midwives, hospital coordinater, CODE)
- Analgesia to counteract shock (100-150mg Pethidine or 15mg Morphine)
- IV access (X2 16G cannula)
- collect blood (FBR, group & hold, coagulation profile, Kleihauer test for fetomaternal haemorrhage)
- IV fluids (volume expanders/plasma expanders/blood transfusion)
- oxygen
- catheter (measure output, protein?, manage fluid balance)
- corticosteroids if
When managing APH where there is maternal or fetal compromise what other issues are vital to consider?
- partner/family
- communication
- psychological care
- prognosis for baby
- transition to parenthood
- impact on future pregnancies
What is disseminated intravascular coagulation (DIC)?
- pathological process where clotting pathways are activated and cause widespread formation of small clots
- uses up available platelets and clotting factors leading to bleeding
What are the 3 main steps in coagulation?
- prothrombin activator is formed
- converts prothrombin to thrombin
- thrombin causes fibrinogen to form a fibrin mesh which traps blood cells and forms a clot
Pregnancy is said to be a hypercoagulable state, what does this mean?
- levels of clotting factors (factor VII, X and fibrinogen) increase in first trimester
- platelets tend to drop in late pregnancy but after birth platelet aggregation increases and thrombin generation increases to prevent excessive bleeding.
What factors may cause DIC?
- sepsis
- severe trauma
- surgery
- cancer
- liver disease
- incompatible blood transfusion
- placental abruption
- intrauterine death
- incomplete miscarriage
- amniotic fluid embolism
- preeclampsia
- PPH
What are the signs and symptoms of DIC?
- bleeding from orifices
- small spots of blood (petechiae) appear under skin
- oozing from venepuncture sites
- lack of clotting
- haematuria
- pallor
- sweating (diaphoresis)
- intracranial haemorrhage (headache, seizures, weakness, loss of motor skills, vision, speech, conciousness)
- may be confirmed by presence of Fibrinogen degradation products (FDPs)
What treatment is necessary for a woman with DIC?
- recognise and treat early
- multidisciplinary team (esp haemotologist)
- replace clotting factors (platelets and fresh frozen plasma)
- vital signs
- renal function
- support for the woman and her family - significant risk of death
What is spontaneous abortion/miscarriage?
involuntary loss of pregnancy in first 20 weeks of pregnancy
What is early miscarriage?
loss of pregnancy in first 12 weeks of pregnancy
What is threatened miscarriage?
uterine bleeding in first 20 weeks with cervix open and no products of conception passed
What is incomplete miscarriage?
uterine bleeding in first 20 weeks with cervix open, some but not all products passed
What is inevitable miscarriage?
uterine bleeding in first 20 weeks with cervix open, contractions and no products passed
What is a missed miscarriage?
fetus/embyro demised, cervix closed, no products passed
what is a septic miscarriage?
an incomplete miscarriage in which infection has ascended and causes endometritis
What is a subchorionic haemorrhage?
bleeding between the chorion and the uterine wall on USS
What is implantation bleeding?
a small amount of pink or brownish discharge, spotting of dark blood, light cramping, may last up to a couple of days, caused by injury to maternal cells when the fertilized egg implants in the uterus, 6-12 days after conception around time when next period is due
What are the risk factors for ectopic pregnancy?
- previous pelvic surgery
- history of tubal ligation
- history of pelvic inflammatory disease
- contraception with progesterone only pills
- pregnancy with IUD
- previous ectopic pregnancy
- smoking
- increased maternal age
If a woman has a Rh -ve blood group and is experiencing a sensitising event when should she be offered Anti-D?
- within 72 hours
- possibly protective within 9-10 days
What are 4 first trimester sensitising events?
- miscarriage
- termination
- ectopic pregnancy
- chorionic villus sampling
What are 6 second trimester sensitising events?
- genetic studies (CVS, amniocentesis)
- abdominal trauma (even if kleihauer neg)
- antepartum haemorrhage
- external cephalic version
- threatened or actual miscarriage
- termination
What are the main steps in clotting?
- activation of clotting factors
- activation of prothrombin activator
- prothrombin converts to thrombin
- stimulates fibrinogen to become fibrin
- forms a fibrin mesh-blood clot
- products of coagulation are broken down by fibrinolysis when no longer needed
