Bleeding in Pregnancy

Question 1

give a definition of ante-partum haemorrhage

Answer 1

bleeding after 24 weeks gestation

Question 2

name the common causes of ante-partum haemorrhage

Answer 2

Placenta praevia

Placental abruption

Vasa praevia

Uterine rupture

Cervical causes - polyp / Ca / infection

“Show”

Other - haematuria / PR bleed

Unknown (25-30%)

Question 3

define placenta praevia

what are the risk factors?

Answer 3

Abnormally sited placenta - all or part of the placenta implants in the lower uterine segment

Placenta lies in front of the presenting part

1% of pregnancies

More common in Multiparous, Multiple pregnancy, Previous CS

Bleeding from maternal circulation

Question 4

what are clinical features and diagnosis of placenta praevia?

Answer 4

Small / large volume blood loss

Painless

May have recurrent bleeding

Soft uterus - fetus easy to palpate

High presenting part - head not engaged

Malpresentation - Breech / Transverse Lie

CTG - usually no fetal distress

Diagnosis- Ultrasound

Question 5

what examination should you net do until placenta praevia has been excluded?

Answer 5

Vaginal Examination

Question 6

what are the clinical signs of abruption?

Answer 6

Small or large volume blood loss

Painful

Uterine activity

Signs may be inconsistent with revealed blood

Tense, tender uterus. Large for dates

Difficult to feel fetal parts

CTG - may be poor (?Intra-uterine Death)

Question 7

describe the differences in clinical features between PP, Abruption and a local injury

Answer 7

Question 8

define vasa praevia

Answer 8

vessels infront of external uterine orifice

Velamentous (veil like) insertion of cord / succenturate lobe

Fetal vessel within membranes

Question 9

outline rhesus disease pathophysiology?

What is the treatment?

Answer 9

rhesus negative mother has rhesus positive baby

first pregnancy mother becomes sensitised but usually there is no problem. 2nd or third pregancy anti-D antibodies cross the placents and destroy foetal blood

Anti-D immunoglobulin destroys foetal blood cells that have crossed the placenta before mother can form anti-D antibodies

Routine antenatal anti-D prophylaxis (RAADP)

There are currently two ways you can receive RAADP:

a one-dose treatment: where you receive an injection of immunoglobulin at some point during weeks 28 to 30 of your pregnancy

a two-dose treatment: where you receive two injections; one during the 28th week and the other during the 34th week of your pregnancy

Question 10

under what circumstances are steroids given?

What type of steroids?

Answer 10

respiratory distress

up to 36 weeks

IM betamethasone 2x12mg 12 hours apart

Question 11

what are the definitions of minor/moderate/major post partum haemorrhages?

Answer 11

Minor PPH <500ml

Moderate PPH 500-1500ml

Major PPH = >1500ml

Question 12

what are the Ts? for PPH

Answer 12

Aetiology - “4 T’s” :

Tone 70%

Trauma 20%

Tissue 10%

Thrombin <1%

Question 13

how would potential causes of PPH present?

Answer 13

Question 14

what’s initial PPH management?

Answer 14

Uterine massage

5 units iv Syntocinon stat

40 units Syntocinon in 500ml

Hartmanns - 125 ml/h

Most cases respond

Question 15

what is the management of a persistent PPH

Answer 15

Confirm placenta and membranes complete

Urinary Catheter

500 micrograms Ergometrine IV

(Avoid if Cardiac Disease / Hypertension)

Vaginal / perineal trauma - ensure prompt repair

cervical trauma

Call senior help