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Midwifery > Bleeding in pregnancy > Flashcards

Bleeding in pregnancy Flashcards

1
Q

What is the definition of antepartum haemorrhage?

A

bleeding from the genital tract after 20 weeks gestation and before the onset of labour

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2
Q

What is the incidence of antepartum haemorrhage?

A

affects 2-5% of pregnancy

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3
Q

What are 5 main impacts/risks with antenatal haemorrhage?

A
  • maternal stress
  • severe bleeding
  • disseminated intravascular coagulation
  • fetal neurological damage due to hypoxia
  • FDIU/stillbirth/neonatal death
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4
Q

What are the 4 main causes of bleeding in late pregnancy?

A
  • unclassified (47%)
  • vasa praevia (0.5%)
  • placenta praevia (31%)
  • placental abruption (22%)
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5
Q

What are 8 key causes of unclassified or incidental bleeding in pregnancy?

A
  • heavy show/onset of labour
  • cervical ectropion
  • cervicitis (infection)
  • vulvovaginal varicosities
  • polyps
  • trauma
  • haemoturia
  • carcinoma
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6
Q

What is Vasa Praevia?

A
  • where blood vessels in the placenta or umbilical cord are trapped betweent the fetus and the cervix
  • rare - 0.5% of APH
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7
Q

What is Placenta Praevia?

A
  • 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
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8
Q

What is the incidence of placenta praevia?

A

0.3-0.6% of all pregnancies

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9
Q

What are the 4 main risk factors for placenta praevia?

A

risk increases with:

  • parity
  • age
  • smoking
  • previous C/S
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10
Q

What is the recurrence rate for placenta praevia?

A

4-8%

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11
Q

What are 10 complications that may be associated with placenta praevia?

A
  • 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
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12
Q

What are the four grades of placenta previa?

A

1 Edge of placenta in lower segment
2 Entire placenta in lower segment
3 Placenta reaches cervical os
4 Placenta covers cervical os

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13
Q

What signs and symptoms may indicate bleeding is due to placenta praevia?

A
  • 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
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14
Q

How is placenta praevia diagnosed?

A
  • confirmed and graded by ultrasound
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15
Q

What is conservative management for placenta praevia?

A
  • appropriate for slight bleeding with well mother/baby
  • admission
  • strict bed rest
  • serial CTG and US
  • preparation for birth
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16
Q

What is active management of severe haemorrhage caused by placenta praevia and placental abruption?

A
  • immediate preparation for emergency C/S - support, communication
  • IV access 16G cannula
  • FBE, group & hold, clotting
  • IV infusion/blood transfusion to stabilise
  • fetal monitoring
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17
Q

What is placental abruption?

A

premature separation of a normally located placenta >20 weeks gestation

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18
Q

what is the incidence of placental abruption?

A

0.5-2% of pregnancies

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19
Q

List 8 risk factors for placental abruption?

A
  • severe preeclampsia
  • sudden reduction in uterine size (amnio reduction)
  • direct trauma (car accident, violence)
  • high parity
  • previous C/S
  • previous abruption
  • smoking
  • cocaine use
20
Q

What is revealed haemorrhage?

A
  • 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
21
Q

What is concealed haemorrhage?

A
  • 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
22
Q

What 8 complications may be associated with placental abruption?

A
  • 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
23
Q

Why are signs of shock not always associated with bleeding in pregnancy?

A
  • increased blood volume so signs may not present until 25-30% blood loss
  • after fetal circulation has been affected
24
Q

What assessments are vital where a woman presents with bleeding in pregnancy?

A
  • 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)
25
Q

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?

A 
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
26
Q

What management is likely to be necessary if APH with maternal or fetal compromise?

A
  • 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
27
Q

When managing APH where there is maternal or fetal compromise what other issues are vital to consider?

A
  • partner/family
  • communication
  • psychological care
  • prognosis for baby
  • transition to parenthood
  • impact on future pregnancies
28
Q

What is disseminated intravascular coagulation (DIC)?

A
  • pathological process where clotting pathways are activated and cause widespread formation of small clots
  • uses up available platelets and clotting factors leading to bleeding
29
Q

What are the 3 main steps in coagulation?

A
  • prothrombin activator is formed
  • converts prothrombin to thrombin
  • thrombin causes fibrinogen to form a fibrin mesh which traps blood cells and forms a clot
30
Q

Pregnancy is said to be a hypercoagulable state, what does this mean?

A
  • 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.
31
Q

What factors may cause DIC?

A
  • sepsis
  • severe trauma
  • surgery
  • cancer
  • liver disease
  • incompatible blood transfusion
  • placental abruption
  • intrauterine death
  • incomplete miscarriage
  • amniotic fluid embolism
  • preeclampsia
  • PPH
32
Q

What are the signs and symptoms of DIC?

A
  • 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)
33
Q

What treatment is necessary for a woman with DIC?

A
  • 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
34
Q

What is spontaneous abortion/miscarriage?

A

involuntary loss of pregnancy in first 20 weeks of pregnancy

35
Q

What is early miscarriage?

A

loss of pregnancy in first 12 weeks of pregnancy

36
Q

What is threatened miscarriage?

A

uterine bleeding in first 20 weeks with cervix open and no products of conception passed

37
Q

What is incomplete miscarriage?

A

uterine bleeding in first 20 weeks with cervix open, some but not all products passed

38
Q

What is inevitable miscarriage?

A

uterine bleeding in first 20 weeks with cervix open, contractions and no products passed

39
Q

What is a missed miscarriage?

A

fetus/embyro demised, cervix closed, no products passed

40
Q

what is a septic miscarriage?

A

an incomplete miscarriage in which infection has ascended and causes endometritis

41
Q

What is a subchorionic haemorrhage?

A

bleeding between the chorion and the uterine wall on USS

42
Q

What is implantation bleeding?

A

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

43
Q

What are the risk factors for ectopic pregnancy?

A
  • 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
44
Q

If a woman has a Rh -ve blood group and is experiencing a sensitising event when should she be offered Anti-D?

A
  • within 72 hours

- possibly protective within 9-10 days

45
Q

What are 4 first trimester sensitising events?

A
  • miscarriage
  • termination
  • ectopic pregnancy
  • chorionic villus sampling
46
Q

What are 6 second trimester sensitising events?

A
  • genetic studies (CVS, amniocentesis)
  • abdominal trauma (even if kleihauer neg)
  • antepartum haemorrhage
  • external cephalic version
  • threatened or actual miscarriage
  • termination
47
Q

What are the main steps in clotting?

A
  • 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

Midwifery (27 decks)

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