Complications during pregnancy - Haemorrhage Flashcards
Antepartum Haemorrhage
Early gestation bleeding:
Ectopic or ruptured ectopic
Miscarriage
Late gestation bleeding:
Placenta praaevia
Placental abruption
Vaginal bleeding during pregnancy is abnormal
Pregnant women may appear well even with large blood loss
visible 50mls of blood is a red flag
Revealed haemorrhage cause
Miscarriage
Placenta previa
Concealed haemorrhage cause
Ruptured ectopic
Placental abruption
S and S: pain, hypovolaemic shock
Causes of haemorrhaging in early pregnancy 24 weeks and under
Miscarriage
Ectopic
Ruptured ectopic
Causes of haemorrhaging in late pregnancy >24 weeks
Placenta previa
Placental abruption
NB. late bleeding will always be placenta related
Miscarriage aetiology
loss of pregnancy before 23 weeks gestation
Majority occur in first trimester (12 weeks)
Commonly seen at 6-14 weeks.
15% of confirmed pregnancy result in miscarriage
Miscarriage pathophysiology
Products of conception are partly passed through the cervix, become trapped leading to blood loss
Situation resolves with removal or expulsion of the products
Incomplete miscarriage - remnants of placenta remain within the uterus causing excessive bleeding and can be fatal. Common complication of septic miscarriage.
Miscarriage risk factors
previous miscarriage
Previously identified as potential miscarriage at scan
Smoker including passive
Excessive consumption caffeine
Poor management of medical conditions (diabetes, thyroid dysfunction, renal disease)
Risk increases with age
Miscarriage Signs and Symptoms
Bleeding: light or heavy with clots or jelly like tissue.
Pain: Central, cramps, suprapubic, backache. Can be as intense as labour pains.
Signs of pregnancy subsiding: nausea, breast tenderness.
Hypotension and bradycardia: could indicate cervical shock due to retained tissue in the cervix. consider signs of shock.
Syntometrine for miscarriage?
Life threatening bleeding if its a confirmed diagnosis by HCP
Ectopic pregnancy usually presents at what stage?
6-8 weeks
Ectopic risk factors
Previous ectopic
Previous surgery on the uterine tube
An intra-uterine contraceptive device fitted
Sterilisation or reversal of sterilisation
Endometriosis
Previous infects: Pelvic inflammatory disease, Chlamydia, Gonorrhoea
Ectopic pregnancy:
Typical S and S
Acute localised, lower abdominal pain
Vaginal bleeding or spotting. May present as brownish vaginal discharge.
Amenorrhoea (absence of periods).
Signs of blood loss in the abdomen with tachycardia and skin coolness
Ectopic pregnancy:
Atypical S and S
Shoulder tip pain - indicative of bleeding into peritoneal cavity.
Nausea, vomiting and unusual bowel symptoms
Unexplained dizziness and fainting
Antepartum Haemorrhage
Vaginal bleeding in late pregnancy (from 24 weeks) is confined to placental separation.
Placenta praaevia
Placental Abruption
NB. 70% of placental abruption occurs in low risk pregnancies without mitigating risk factors.
Placenta praevia
The placenta is partially or wholly impacted in the lower uterine segment
Segment grows and stretches after 12 weeks of pregnancy
Later week may cause placenta to separate and sever bleeding can occur
Usually presents at 24-32 weeks with small episodes of painless bleeding
more common in multigravidae (2nd+ pregnancy) pregnancy
Mother and foetus at high risk = medical emergency
Placenta praevia risk factors
Previous history of placenta praevia
Previous c-section or other uterine surgery
Advanced maternal age
Multiparity (twins and up) or increasing parity (>2nd birth)
Smoking
Cocain use during pregnancy
Previous spontaneous or induced abortion
Deficient endometrium due to pat history of: Endometriosis, Manual removal of placenta, Curettage (scooping out)
Assisted conception
Placental abruption
Premature separation of a normally situated placenta occurring after the 22nd week of pregnancy.
Bleeding occurs between he placenta and the wall of the uterus, where the placenta has detached from the uterine wall
May be revealed or concealed bleeding.
Placental abruption risk factors
Previous abruption
pregnancy induced HTN/pre-eclampsia
Trauma
Multiple pregnancy (twins)
Threatened miscarriage earlier in current pregnancy
Smoking and substance abuse
previous c-section
Intrauterine infections
Polyhydramnios (excess of amniotic fluid in the amniotic sac)
Haemorrhage occurring in late pregnancy:
Placenta praevia S and S
Continuous severe, sudden abdominal or back pain
commonly concealed bleeding but may have revealed bleeding
50ml of revealed blood loss in pregnancy is considered significant
Tender abdomen - rigid or woody. no signs of relaxation
warning bleeding presentation
usually no abdominal pain
Bright red, fresh blood
Degree of shock proportional to blood loss,
Uterus feels soft, non-tender
abdominal girth equal to gestation
Haemorrhage occurring in late pregnancy:
Placental abruption S and S
May or may not have vaginal bleeding
Sudden continuous severe abdominal pain
Back pain; uterine contractions
Degree of shock disproportional to blood loss (if revealed)
Uterus feels tense, hard, woody, no signs of relaxation
Abdominal girth: concealed haemorrhage may lead to uterine enlargement in excess of gestation.
Haemorrhage occurring in late pregnancy:
Uterine rupture
One of the most serious complications of obstetric emergencies.
Complete - tear in the wall of the uterus(with or without expulsion of the foetus)
Incomplete - tearing of the uterine wall but not perimetrium.
Rare and tends to occur during labour
Often fatal for foetus and can cause maternal death
If complete, may require immediate C-section to deliver foetus and may require emergency hysterectomy for the mother.
Causes of uterine rupture:
Previous C-section
High parity
Obstructed labour e.g. shoulder dystocia, pressure or excess thinning of uterus
Previous uterine trauma from assisted birth e.g. forceps
Trauma e.g. blast injury, seatbelt injury
Uterine rupture S and S:
Complete rupture
Maternal tachycardia and signs of shock
Sudden collapse of mother
Sever abdominal pain
Vaginal bleeding
Uterine contractions may stop
Fetus may be palpable in abdomen
Scar pain and tenderness
Movement away of the presenting part
Uterine rupture S and S:
Incomplete rupture
May have minimal pain or blood loss
Labour may progressive’s normally
Disproportionate signs of haemorrhagic shock in the third stage of labour. - May manifest as postpartum haemorrhage.
Movement away of the presenting part
