Bleeding in pregnancy

Question 1

definition of bleeding in early pregnancy?

-late pregnancy

Answer 1

<24 weeks

-antepartum haemorrhage
bleeding form genital tract after 24 wks gestation

Question 2

Antepartum haemorrhage

-function of the placenta?

Answer 2

-Entirely foetal tissue 
source of nutrition from 6 wks
Gas transfer
Metabolism/waste disposal 
Hormone production (HPL & hGh-V)
filter
very vascular (expelled "harmlessly")

Question 3

Causes of antepartum haemorrhage? (5)

Answer 3

placenta previa
Placental abruption 
Local causes- polyps/cancer/infection
Vasa previa
uterine rupture

Question 4

Placental abruption

• definition?
• what are the risk factors?
• name the 2 different types?
• complications? (4)
• give the clinical features (7)
• investigations?

Answer 4

-seperation of a normally implanted placenta (partially or totally) before the birth of the foetus

-pre-eclampsia/hypertension
Trauma/domestic violence
smoking/cocaine/amphetamine
Medical (thrombophilias, renal disease, DM)
Polyhydramnios, multiple pregnancy, Preterm-PROM
Abnormal placenta

-revealed (bleeding) & concealed (no bleed)

-Couvelaire uterus
Post partum haemorrhage
DIC
Feotal/meternal death

-small/large vol blood loss
painful 
uterine tenderness
Uterus feels larger and woody hard 
difficulty feeling foetal parts 
abnormal contractions

-CTG- clinical Dx

Question 5

Placenta Previa

• definition?
• give the classifications? (4, 1, 2)
• clinical presentation? (4)
• CTG?
• diagnosis?
• caution in what examination?
• type of delivery? (2)

Answer 5

-placenta is partially or totally implanted in the lower uterine segment

• Lateral, marginal, incomplete centralis, complete centralis
  graded I-IV
  Major or minor (distance from cervix by US)

-Painless, recurrent 3rd trimester bleeding
amount of blood varies
Uterus soft & non tender 
Malpresentations 
High head

• CTG usually normal
• via US
• DO NOT PERFOM VAGINAL EXAMINATION UNTIL EXCLUDED

-major (<2cm from os) then C-section
Minor (>2cm from os) then C-section

Question 6

Placenta Accreta & Percreta

• definition?
• complications? (3)
• risk factors? (2)

Answer 6

-Accreta
Placenta invades myometrium
Percreta
Placenta has reached serosa

• Assoc with severe bleeding, PPH and hysterectomy
• placenta praaevia & prior C section

Question 7

Uterine rupture

• risk factors?
• clinical presentation? (5)

Answer 7

-previous CS, uterine surgery

-obstructed labour 
peritonism 
foetal head high 
foetal distress/ IUD 
Haematuria

Question 8

Vasa praevia

• definition?
• Dx?
• complications?

Answer 8

• velamentous insertion of cord/succenturate lobe and foetal vessels within membranes
• ante-natally
• foetal death

Question 9

clinical indications suggesting local cause of APH?

Answer 9

-Small vol blood
painless
provoking factor
Uterus soft & non tender
No foetal distress
normally sited placenta

Question 10

Management of Antepartum haemorrhage

• Hx? (7)
• placenta praaevia management? (6)
• placental abruption management?

Answer 10

-bleeding
pain
contractions
Foetal movement
Post-coital?
Smear Hx
Scan Hx

-Admit
IV access- blood tests/cross match
scan
Anti-D
Steroids
Delivery
(major bleeding then likely preterm delivery
C-section at 37-38 wks if there has been prior bleeding in pregnancy or suspected/confirmed placenta accrete
C-section at 38-39 wks if there has been no bleeding in preg)

-Admit
Iv access, bloods & cross match
reuses, manage DIC 
Deliver viable baby
Paediatrician 
stillbirth then vaginal delivery 
Anti-D
steroids

Question 11

Why are steroids given as part of management?

• drug used?
• course?

Answer 11

promote foetal lung surfactant production
reduced risk of neonatal resp distress syndrome, given 24-48 hrs before delivery
administer up to 36 wks

• Betamethasone preferred to dexamethasone
• 1 course= 12mg betamethasone IM x2 injections 12 hrs apart

Question 12

how should delivery be planned for Placenta Accreta?

• how many wks?
• prior arrangements? (3)

Answer 12

-at 37 weeks, document surgical plan

-6 units cross matched blood
arterial line prior to surgery
cell salvage

Question 13

Steps taken in admission of pregnant women with PV bleed?

• investigations? (4)
• administer what? (1)
• what shouldn’t be administered? (1)

Answer 13

-(after wide bore venous access)
FBC, blood group, cross-match, Kleihaure test

• Anti-D if Rh -ve
• enoxaparin thromboprophylaxis, mobilisation & hydration only

Question 14

Post partum haemorrhage

• definition? (4)
• Aetiology: 4 T’s
• complications? (9)
• risk factors (antenatal 5, intrapartum 3)
• Give 6 causes
• initial manegement? (3)
• management if persistent? (3) drugs given? (2)
• give non-surgical (4)and surgical (5) treatments

Answer 14

-Minor <500ml
Moderate 500-1500ml
Major >1500ml
primary (24 hrs) or secondary ( >24 hrs)

• Tone, Trauma, Tissue, Thrombin
• maternal fatigue, feeding probs, prolonged stays, delayed lactation, pituitary infarct, transfusion, haemorrhagic shock, DIC, death

-antenatal 
anaemia
prev C-section
placenta praevia/percreta/accreta
prev PPH or retained placenta 
multiple preg 

intrapartum
prolonged labour
operative delivery
retained placenta

-Uterine atony 
retained placental tissue 
vaginal, cervical, perineal trauma
inverted uterus
ruptures uterus
coagulopathy 

-uterine massage
5 units IV syntonin
40 units syntocin in 500ml Hartmanns- 125ml/h

-confirm placenta and membranes complete
urinary catheter
get blood products 
500mcg Ergometrine IV 
trauma- repair
Carbaprost /Haemabate 250mcg IM

-Non-surgical 
packs and balloons 
tissue sealants
factor VIIa
arterial embolisation 

surgical 
under suturing 
brace sutures
uterine artery ligation 
Internal iliac artery ligation
hysterectomy