Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Gynaecology > HAEMORRHAGE > Flashcards

HAEMORRHAGE Flashcards

1
Q

Define antepartum haemorrhage

A

Bleeding from or into genital tract from 24 weeks gestation (viability) and prior to birth of baby (until first and second stage labour)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Name 4 main causes antepartum haemorrhage

A
  • Abruptio placenta
  • placenta praevia / vasa praevia
  • local causes: lacerations, infection (cervicitis,vaginitis), cancer, trauma, warts, ulcers…
  • APH of unknown origin

( Uterine rupture )

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Name 8 risk factors antepartum haemorrhage caused by abruptio placenta

A

Placental factors

  • previous abruption

Maternal factors

  • pre-eclampsia !, hypertensive disease in pregnancy
  • SLE , APLS (antiphospholipid syndrome)
  • AMA
  • Poor social economic status, multiparity
  • smoking and drug use (cocaine)

Uterine /pregnancy factors

  • fetal growth restriction: polyhydramnios
  • prom
    -, multiple gestation
  • intra-uterine infection

Mechanical

  • abdominal trauma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Name 8 causes / risk factors antepartum haemorrhage caused by placenta praevia

A

Placental factors

  • Previous placenta praevia
  • Placentomegaly, abnormal formation of placenta

Endometrial factors

  • previous C section
  • previous top
  • congenital uterine abnormalities
  • Deficient endometrium eg uterine scar, Endometritis , curettage, myomectomy
  • multiple pregnancy

Lifestyle

  • smoking
  • AMA

Conceptus related factors

  • assisted conception
  • delay in development/ maturation of fertilised ovum
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Cause of tense/ woody uterus?

A

Significant abruption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When should digital examination be avoided?

A

Placenta praevia
Premature rupture of membranes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Management antepartum haemorrhage? (9)

A
  • Determine if shocked and resuscitate
  • admit if APH heavier than spotting, and ongoing bleeding, until stopped. If placenta praevia and bled, hospitalise until delivery
  • history for risk factors
  • examination : no pv until exclude praevia!
  • investigations: blood, ultrasound
  • check baby: ga, ctg
    /
  • manage according to cause
  • corticosteroids 26 -34 weeks if risk preterm
  • tocolysis only if mom and baby stable
  • if foetal death→ vaginal delivery with active manage 3rd stage labour
  • foetal compromise → c/s immediately
  • if unexplained APH and no maternal/foetal compromise, plan delivery at 37 weeks
  • continuous ctg if active bleeding, early pregnancy major APH, recurrent minor APH, clinical abruption, evidence placental insufficiency
  • anti D ig to all non sensitised Rh negative independent of whether routine prophylaxis has been given. If recurrent bleeding after 20 weeks, give anti-d at 6 weekly intervals
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Define primary postpartum haemorrhage

A

First 24 hours after delivery
Blood loss > 500 ml after vaginal, 1000 ml after c/S

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Define secondary postpartum haemorrhage

A

24 hours - 6 weeks after delivery

> 500 ml vaginal, 1000 c/s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Define persistent postpartum haemorrhage

A

Active bleedin > 1000 ml within 24 hours following birth that continues despite use initial measures including uterotonics and massage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Prevention postpartum haemorrhage (6)

A
  • Active management 3rd stage labour:
    → uterotonic
    > uncomplicated vaginal: syntocinon 5 or 10 iu IM
    > C section: syntometrine (oxytocin/ ergometrine) 2,5 iu by slow iv injection
    > CVS disorders: low dose infusion oxytocin safer than bonus
    → early clamping umbilical cord
    → controlled traction for placental delivery for potential risk PPH
  • all with previous c/s, determine placental site un ultrasound. Prepare for resuscitation if any abnormalities diagnosed
  • iron supplements antenatally if iron deficiency anaemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Name 5 causes postpartum haemorrhage

A

4 Ts

  • tone: uterine atony
  • Trauma to genital tract
  • thrombosis: coagulation defects
  • tissue: retained products of conception
  • uterine inversion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Stepwise Medical treatment uterine atony? (7)

A
  • Bimanual uterine compression
  • Ensure empty bladder -catheter
  • syntocinon (oxytocin/ergometrine) 5 iu by slow iv injection (may be repeated)
  • ergometrine 0,5 mg slow iv (contraindicated in ht)
  • syntocinon infusion 30 iu in 1L ringer’s
  • tranexamic acid 500 - 1500 mg iv
  • misoprostol 1000 ug rectally
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Approach to postpartum haemorrhage after vaginal delivery? (10)

A

Resuscitate
→ rub up uterus/ bimanual compression
→ call for help
→ 2 large bore iv
→ infusion oxytocin 20 U in 1 L ringers
→ maintain bp with clear fluids/blood
→ catheter
→ monitor bp/pulse/urine output

Check placenta

  • undelivered: repeat cord traction and manually remove
  • incomplete: evacuate uterus, digital exploration , ovum forceps and largest curette

If complete /ongoing bleed, check uterus

  • soft
    → massage uterus and expel clots
    → continue oxytocin infusion
    → ergometrine 0,5 mg or syntometrine 1 amp IM (repeat once if, needed)
    → misoprostal 400 - 600 ug Pr or sublingual
    → tranexamic and 1 G iv ( can repeat x 1)
  • Firm: suture lacerations perineum, vagina, cervix
  • not felt: check vaginally for inverted uterus
    → replace immediately
    → hydrostatic reduction: saline infusion into vagina. Hold vulvae around tube or use rubber vacuum cup in vagina forseal

If ongoing bleedin

  • tranexamic acid 1 g iv
  • examine in theatre , while wait place anti shock garment and balloon tamponade to reduce bleed,
  • explore for retained products and deep lacerations
  • laparotomy:
    → aortic compression
    → uterine compression sutures ( b lynch)
    → uterine artery ligation
    → hysterectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Management PPH after vaginal delivery + resus, with soft uterus? (5)

A

→ massage uterus and expel clots
→ continue oxytocin infusion
→ ergometrine 0,5 mg or syntometrine 1 amp IM (repeat once if, needed)
→ misoprostal 400 - 600 ug Pr or sublingual
→ tranexamic and 1 G iv ( can repeat x 1)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management ongoing PPH after vaginal delivery , when resuscitation has been performed and placenta and uterus examined and managed? (7)

A
  • tranexamic acid 1 g iv
  • examine in theatre , while wait place anti shock garment and balloon tamponade to reduce bleed,
  • explore for retained products and deep lacerations
  • laparotomy:
    → aortic compression
    → uterine compression sutures ( b lynch)
    → uterine artery ligation
    → hysterectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Approach to management post partum haemorrhage after ceserean section (6)

A
  • Call for more senior help
  • resuscitates / early treatment by anaesthetist
  • arrest haemorrhage (surgeon) (proceed immediately to subtotal hysterectomy irreparable uterine rupture or placenta percreta )

Determine cause

  • atonic uterus:
  • tears:
  • Placental site bleeding:
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Classify perineal tears (6)

A
  • First degree: injury to perineal skin only
  • second: involve perineal muscles but not anal sphincter
  • third: involve anal sphincter complex
    → 3a: < 50% of external anal sphincter thickness torn
    → 3b: > 50%
    → 3c: both external and internal anal sphincter torn
  • fourth: involve anal sphincter complex (internal and external) and anal epithelium
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Define buttonhole tear. Complication?

A

Involve only anal mucosa with intact anal sphincter complex, must be documented as separate entity to perineal tear.
Can → anovaginal fistula

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

How repair first and second degree perineal tear?

A

Bedside sutures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How repair third and fourth degree perineal tear? (3)

A

In theatre.

External anal sphincter: overlapping or end to end (approximation) method with monofilament sutures ( eg PDS polydiaxanone ) or modern braided sutures (vicryl polyglactin)

Internal: interrupted fine sutures with 3-0 PDS or 2-0 vicryl

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Post op and repair management perineal tears? (5)

A
  • Laxatives: lactose 15 ml bd po x 10 days
  • antibiotics: cefuroxime (cephalosporin 2nd gen) 1,5 G TDS iv + metronidazole 500 mg TDS iv x 5 days
  • follow up
  • symptomatic patients (dehiscence and infection): evaluate with endoanal scan and anal manometry
  • most will be asymptomatic at 12 months after repair
23
Q

Define acute uterine inversion

A

Collapse uterine fundus into endometrial cavity

24
Q

Name 4 risk factors acute uterine inversion

A
  • Excess cord traction
  • fundal pressure
  • fundal cord insertion
  • abnormal plantation
25
Q

Name a symptom and 4 signs acute uterine inversion

A

Symptoms

  • severe lab in 3rd stage labour

Signs

  • haemorrhage
  • severe shock
  • placenta may/ may not be attached
  • uterine fundus
26
Q

Management acute uterine inversion (7)

A
  • call for help
  • monitor vital signs, ensure head of bed is flat
  • Immediately try to correct inversion by grab uterus with palm and fingers posteriorly, thumbs anteriorly. Do not use fist. Do not remove placenta from inverted uterus
  • resuscitate: insert 2 large iv with fluids, give face mark oxygen
  • withold uterotonic agents and consider uterine relaxing agents
    /
  • o’sullivan’s hydrostatic technique first-line
  • balloon catheter
  • surgical intervention at laparotomy
27
Q

Describe o’ Sullivan’s hydrostatic technique to correct uterine inversion (9)

A
  • First exclude uterine rupture
  • iv salbutamol up to 250 ug
  • position in lithotomy
  • run 2 l warmed irrigation fluid (saline) into vagina by gravity or pressure.
  • Seal vagina with silastic ventouse cup. May need retention sutures in fourchette
  • if unsuccessful, repeat or consider surgical management
  • once corrected, manually remove placenta in theatre if still attached
  • stat dose oxytocin 10 iu iv
  • commence oxytocin infusion 20 - 40 u in 1 l ringers at 125 ml/h
28
Q

Name 2 surgical interventions that can be performed after attempting o’sullivan’s hydrostatic technique to correct uterine inversion

A
  • Huntington procedure: clamps on round ligaments 2cm deep in the inversion and gentle upward traction.
  • haultain procedure: incision in posterior portion of inversion ring to increase size and to reposition the uterus
29
Q

How can antepartum haemorrhage present? (5)

A
  • Concealed bleed
  • spotting
  • minor haemorrhage: < 50 ml
  • major haemorrhage: 50 - 1000 ml without shock
  • massive haemorrhage: > 1000 ml with or without shock
30
Q

Define placenta praevia

A

Implantation of placenta partially/completely in lower segment uterus within 2 cm of cervix

31
Q

Name 2 symptoms and 4 signs placenta praevia?

A

Symptoms

  • Painless pv bleed after 20 weeks
  • bright red blood

Signs

  • uterus soft, non-tender/ irritable
  • presenting part not engaged/high
  • abnormal / unstable lie
  • Maternal CVS compromise; foetal compromise
32
Q

Name 6 maternal complications of placenta praevia

A
  • Major APH, shock, death
  • Pph
  • anaemia (chronic haemorrhage)
  • Rh sensitisation
  • coagulopathy /dic
  • morbidly adherent placenta: placenta accreta (grow too deep into uterus) occurs in 10% of praevia
33
Q

Name 2 foetal complications of placenta praevia

A
  • Prematurity
  • foetal insult → hie, cp, intrauterine foetal demise
34
Q

Management placenta praevia? (3)

A

Mother unstable: c/s

Mother stable and Ga < 34 weeks

  • admit until delivery and stabilise
  • steroids
  • expectant management.
  • deliver via cs at 34 weeks

Ga > 34 weeks

  • stabilize and deliver via c/s (elective)
  • emergency if persistent bleed or symptomatic
35
Q

Define abruptio placenta

A

Premature separation placenta from uterine wall with or without pv bleed in viable gestation

36
Q

Name 3 types abruptio placenta

A
  • concealed
  • revealed
  • mixed
37
Q

Name 2 symptoms and 3 signs abruptio placenta

A

Symptoms

  • Pv bleed: dark and clots
  • continuous abdominal pain not alleviated between contractions

Signs

  • “woody” hard uterus with pain and tender
  • FHR ctg changes
  • maternal hypovolaemic shock
38
Q

Specific Management abruptio placenta?

A

Mom unstable → emergency cs unless imminent delivery

Foetus alive and viable → emergency cs unless imminent delivery

Foetus dead/ not viable → stabilise mom and aim for vaginal delivery

39
Q

Name 9 maternal complications abruptio placenta

A
  • hypovolaemic/ haemorrhagic shock
  • PPH
  • coagulopathy/DIC
  • Amniotic fluid embolism
  • Rh sensitisation
  • organ dysfunction / failure
  • Acute tubular necrosis
  • Sheehan’s syndrome (severe blood loss causing pituitary injury)
  • death
40
Q

Define vasa praevia

A

Rupture of foetal vessels running within membranes, often near cervical os and damaged when membranes rupture

41
Q

Name 3 risk factors vasa praevia

A
  • Placenta praevia
  • vilamentous placental insertion
  • multiple pregnancy
42
Q

Define uterine rupture

A

Non - surgical disruption/tear of myometrium with or without serosa of uterus, with or without expulsion of foetus and placenta.

43
Q

Name 4 risk factors uterine rupture

A
  • C section, esp classical
  • scarred uterus other than c/s: hysterOtomy, myomectomy, previous perforation
  • surgical intervention: internal version, forceps delivery
  • medical intervention: induction agents
44
Q

Name 6 signs of imminent uterine rupture

A
  • Excessive uterine activity
  • overdistended lower uterine segment
  • oedematous cervical os margins
  • difficult urination/haematuria
  • bloody discharge!
  • Foetal tachycardia/decels
  • abdominal pain between contractions
  • sudden cessation of contraction
  • Pathological contractile bandl ‘ s ring
45
Q

Name 8 signs uterine rupture

A
  • Acute abdomen especially between contractions
  • shock, intra-abdominal haemorrhage features: tachycardia, hypotension, fainting
  • easily palpable foetal parts
  • absent foetal heart sound, abnormal ctg
  • contracted uterus felt on one side
  • vaginal bleeding, haematuria
  • cessation of previously efficient uterine activity
  • loss of station/ presenting part
46
Q

Name 5 risk factors uterine atony

A
  • Precipitous/protracted labour
  • uterine overdistension
  • grand multiparity
  • chorioamnionitis
  • medications: mgso4, beta agonists, halogenated anaesthetics
47
Q

Diagnosis uterine atony?

A

Clinical

  • soft, boggy
  • enlarged above umbilicus
48
Q

Specific treatment uterine atony? (3)

A
  • Uterotonics
  • fundal massage
  • B lynch suture
49
Q

Name 3 risk factors retained products of conception

A
  • Accessory placental lobe
  • abnormal plantation (depth eg accreta / location)
  • operative vaginal delivery
50
Q

Name 3 placental attachment disorders

A
  • Placenta accreta (placental villi invade surface of myometrium)
  • increta (extend into myometrium)
  • percreta (through myometrium into serosa)
51
Q

Name 8 ultrasound features of morbidly adherent placenta

A

Greyscale

  • loss or irregular retroplacental sonolucent zone (clear space excludes it)
  • thinning /disruption hyperechoic serosa - bladder interface
  • exophytic masses invading bladder
  • abnormal placental lacunae

Doppler

  • diffuse/focal lacunar flow
  • vascular lakes with turbulent flow
  • hypervascularity of serosa - bladder interface
  • markedly dilated vessels over peripheral subplacental zone
52
Q

Dose ergometrine

A

0,5 mg IM, repeat X1 if needed

! Contraindicated in cardiac patients

53
Q

Dose misoprostol for PPH

A

400 - 600 ug (2-3 tabs) Pr

54
Q

Classification of abruptio placenta?

A

Grade 1: mild, often retroplacental clot ID’d retrospectively after delivery
Grade 2: tense, tender abdomen, live foetus
Grade 3: with foetal demise
- 3a: without coagulopathy
- 3b: with coagulopathy

Gynaecology (40 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions