Bleeding in pregnancy

Question 1

What is ante-partum haemorrhage?

Answer 1

Bleeding from the genital tract after 24 weeks gestation

Question 2

What are the causes for antepartum haemorrhage?

Answer 2

λ	Placenta praevia
λ	Placental abruption
λ	Vasa praevia 
λ	Uterine rupture
λ	Cervical causes - polyp / Ca  / infection
λ	“Show”
λ	Other - haematuria / PR bleed
λ	Unknown (25-30%)

Question 3

What is pacenta praevia?

Answer 3

λ Abnormally sited placenta - all or part of the placenta implants in the lower uterine segment
λ Placenta lies in front of the presenting part

Question 4

How common is placenta praevia? what is this more common in?

Answer 4

λ 1% of pregnancies
λ More common in Multiparous, Multiple pregnancy, Previous CS

λ The incidence decreases after 20weeks to term as it ‘migrates’ up

Question 5

How does placenta praevia present?

-what is seen on CTG?

Answer 5

¥ Small / large volume blood loss

¥ Amount of blood variable and you can have lots of blood in minor and little bood in major vice versa

¥ Painless/no contractions

¥ May have recurrent bleeding

¥ Everytime the uterus gets bigger, placenta separates slightly = recurrent bleeding
¥ ?Scan history

¥ Soft uterus - fetus easy to palpate

¥ High presenting part - head not engaged

¥ Malpresentation - Breech / Transverse Lie

¥ CTG - usually no fetal distress

Question 6

How is placenta praevia diagnosed?

Answer 6

• Ultrasound – if find it low at 20wks do another scan at 32/34 wks
• DO NOT PERFORM VAGINAL EXAMINATION UNTIL P/P HAS BEEN EXCLUDED

Question 7

What does delivery with placenta praevia depend on?

Answer 7

• Depends on distance from cervical os

Question 8

What is placenta accreta?

Answer 8

This is when all or part of the placenta attaches abnormally to the myometrium. (it should be attached to decidua) Three grades of abnormal placental attachment are defined according to the depth of invasion.

Question 9

What is placental abruption?

Answer 9

λ Premature separation of normally sited placenta
λ Revealed / Concealed - revealed is that bleeding is seen (80%)
λ The blood can go out onto the muscle, or into liquor, or out cervix

This can be due to polyhydramnios and when this ruptures quickly the placenta separates due to negative pressure

Question 10

What 4 things can this lead to?

Answer 10

λ Couvelaire uterus
-Bleeding penetrates into the uterine myometrium forcing its way into the peritoneal cavity

λ Post partum Haemorrhage

λ DIC – disseminated intravascular coagulation
-The blood causes clotting factors to come and clot blood - Small blood clots form in the blood vessels. Some of these clots can clog the vessels and cut off blood supply to organs such as the liver, brain, or kidneys. Lack of blood flow can damage the organ and it may stop working properly.

λ Fetal death / Maternal death

Question 11

What are the clinical features? what is seen on CTG?

Answer 11

λ Small or large volume blood loss
λ Painful
λ Uterine activity (contractions)
λ Signs may be inconsistent with revealed blood
λ Tense, tender uterus. Large for dates
λ the myometrium is a wooden hard consistency as blood causes spasm here
λ Difficult to feel fetal parts
λ CTG - may be poor (?Intra-uterine Death)

Question 12

How is placental abruption diagnosed?

Answer 12

Don’t need US to diagnose abruption – it wont show a small abruption
• Clinical diagnosis
• Still do US to rule out P/P

Question 13

What would be thought of if volume of blood was small, no pain and no contraction, uterus soft non tender, fetus is normal presentation and no fetal distress?

Answer 13

-local causes

Question 14

What is vasa praevia?

Answer 14

A condition in which blood vessels within the placenta or the umbilical cord are trapped between the fetus and the opening to the birth canal

Question 15

What is uterine rupture? when is this most likely to happen?

Answer 15

• There’s a weakness in the muscle and uterus ruptures

Usually during labour as there’re lots of contractions

Question 16

Describe the clinical features of uterine rupture

Answer 16

λ	Small / Large volume
λ	Previous CS / uterine surgery
λ	Obstructed Labour
λ	Peritonism
λ	Fetal head high
λ	Fetal distress / IUD
λ	Haematuria
λ	Requires laparotomy / CS

Question 17

What is important to ask in the history of a patient who has bleeding in pregnancy?

Answer 17

λ	Bleeding
λ	Pain – abruption?
λ	Contractions – in labour?
λ	Fetal movements
λ	Post-coital?
λ	Smear history
λ	Scan history – detect P/P
λ	Anybody who bleeds after 12 weeks who is rhesus negative gets anti-D
λ	250 units < 20wks, 500units > 20wks

Question 18

What is included in the examination of someone who has bleeding in pregnancy?

Answer 18

¥	ABCDE
¥	Assess volume of APH
¥	Fundal height
¥	Uterine tenderness
¥	Uterine activity
¥	Fetal lie and presentation
¥	Auscultation of Fetal Heart / CTG

DONT DO VAGINAL EXAM BEFORE SCAN

Question 19

What is the initial management of bleeding in pregnancy?

Answer 19

λ	IV Access
λ	Full Blood Count
λ	Coagulation Screen
λ	Rhesus status - Kleihauer + Anti-D
λ	Group and Save / Cross match 2-6 units
λ	IV Fluids
λ	CTG
λ	Ultrasound
λ	Speculum when P/P excluded
λ	Consider Steroids – for fetal lung maturation

Question 20

Steroids for fetal lung maturation:

• what do these promote?
• when are these administered up to?
• what steroids are given?

Answer 20

λ Promote fetal lung surfactant production
λ ↓ neonatal respiratory distress syndrome (RDS) by up to 50% if administered 24-48h before delivery
λ Administer up to 36 weeks. Only significant effects up to 34 weeks. Proven benefit up to 1 week
λ Betamethasone preferred to Dexamethasone
λ 1 course = 12mg Betamethasone IM X2 injections 12 hours apart

Question 21

When is C-section performed with placenta praevia?

Answer 21

38 weeks - sooner if signif. haemorrhage

Question 22

When is delivery commenced with placental abruption?

Answer 22

Delivery viable baby - c sec. vs vagina;

-still birth do vaginal

Question 23

What is the further management for bleeding due to:

• cervical causes
• infection
• pre-term labour
• vasa praevia
• rupture
• unknown

Answer 23

λ	Cervical causes - colposcopy
λ	Infection - swabs / specific treatment
λ	PTL - steroids +/- tocolysis
λ	Vasa praevia - Caesarean section 
λ	Rupture - laparotomy / CS
Unknown - conservative

Question 24

What are the complications of post-partum haemorrhage 9

Answer 24

Maternal fatigue, feeding difficulties, prolonged hospital stay, delayed lactation, pituitary infarction, transfusion, haemorrhagic shock, DIC, death

Question 25

What are the definitions of post-partum haemorrhage:

• primary
• secondary
• minor
• moderate
• major

Answer 25

• “Classic” Definition > 500ml
• Primary - within 24h
• Secondary - >24h - 6/52
• Minor PPH <500ml
• Moderate PPH 500-1500ml
• Major PPH = >1500ml

up to 1litre ok for CS

Question 26

what are the 4 ‘t’s of post-partum haemorrhage causes?

Answer 26

♣ Tone 70%
-Muscle got tired – uterus stopped trying

♣ Trauma 20% - laceration

♣ Tissue 10% - Retained tissue parts

♣ Thrombin<1% - coagulopathy

Question 27

What are the antenatal risk factors for post-partum haemorrhage?

Answer 27

Ð	anaemia
Ð	previous caesarean section
Ð	placenta praevia, percreta, accreta
Ð	previous PPH or retained placenta
Ð	Multiple pregnancy

Question 28

What are the intrapartum risk factors for post-partum haemorrhage 3

Answer 28

Ð prolonged labour
Ð operative vaginal delivery / caesarean section
Ð retained placenta

Question 29

When is active management of the third stage performed?

Answer 29

Ð If risk factors do active management of 3rd stage and pull out placenta that has already separated
Ð If no risk factors can let it come out physiologically but this = more bleeding

Question 30

What cause of PPH would you think of if there was:

• vaginal bleeding
• placenta complete
• uterus soft

Answer 30

uterine atony

Question 31

What cause of PPH would you think of if there was:

• vaginal bleeding
• placenta incomplete
• uterus soft or contracted

Answer 31

retained placental tissue

Question 32

What cause of PPH would you think of if there was:

• Vaginal bleeding
• placenta complete
• uterus well contracted

Answer 32

vaginal/cervical/perineal trauma

Question 33

What cause of PPH would you think of if there was:

• No vaginal bleeding (often)
• mild/severe abdo pain
• symptoms shock
• uterus seen at vulva/no palpated abdominally

Answer 33

inverted uterus

Question 34

What cause of PPH would you think of if there was:

• vaginal bleeding
• severe abdo pain
• shoulder tip pain
• uterus tender/extremely painful on palpation

Answer 34

ruptured uterus

Question 35

What cause of PPH would you think of if there was:

• continual bleeding
• oozing from wound sites
• uterus soft/contracted

Answer 35

coagulopathy

Question 36

What is the initial management for PPH? 5

Answer 36

•	Uterine massage 
•	5 units iv Syntocinon stat
•	40 units Syntocinon in 500ml
•	Hartmanns - 125 ml/h
Most cases respond

Question 37

What is the management for persistant PPH?

Answer 37

λ Confirm placenta and membranes complete
λ Urinary Catheter
λ 500 micrograms Ergometrine IV
(Avoid if Cardiac Disease / Hypertension)
λ ? Vaginal / perineal trauma - ensure prompt repair
? cervical trauma

Question 38

what is the management for persistant management of PPH >1500:

• non-surgical
• surgical

Answer 38

Non - Surgical
λ	Packs & Balloons
λ	Tissue Sealants
λ	Factor VIIa
λ	Arterial Embolisation

Surgical
λ Undersuturing
λ Brace Sutures
λ Uterine Artery Ligation - unlikely
λ Internal Iliac Artery Ligation - unlikely
λ Hysterectomy – hard if not completed their family