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)
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 )
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
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
5
Q
Cause of tense/ woody uterus?
A
Significant abruption
6
Q
When should digital examination be avoided?
A
Placenta praevia
Premature rupture of membranes
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
8
Q
Define primary postpartum haemorrhage
A
First 24 hours after delivery
Blood loss > 500 ml after vaginal, 1000 ml after c/S
9
Q
Define secondary postpartum haemorrhage
A
24 hours - 6 weeks after delivery
> 500 ml vaginal, 1000 c/s
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
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
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
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
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
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)
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
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:
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
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
20
Q
How repair first and second degree perineal tear?
A
Bedside sutures
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
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
Name a symptom and 4 signs acute uterine inversion
Symptoms
- severe lab in 3rd stage labour
Signs
- haemorrhage
- severe shock
- placenta may/ may not be attached
- uterine fundus
26
Management acute uterine inversion (7)
- 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
Describe o' Sullivan's hydrostatic technique to correct uterine inversion (9)
- 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
Name 2 surgical interventions that can be performed after attempting o'sullivan's hydrostatic technique to correct uterine inversion
- 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
How can antepartum haemorrhage present? (5)
- Concealed bleed
- spotting
- minor haemorrhage: < 50 ml
- major haemorrhage: 50 - 1000 ml without shock
- massive haemorrhage: > 1000 ml with or without shock
30
Define placenta praevia
Implantation of placenta partially/completely in lower segment uterus within 2 cm of cervix
31
Name 2 symptoms and 4 signs placenta praevia?
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
Name 6 maternal complications of placenta praevia
- 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
Name 2 foetal complications of placenta praevia
- Prematurity
- foetal insult → hie, cp, intrauterine foetal demise
34
Management placenta praevia? (3)
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
Define abruptio placenta
Premature separation placenta from uterine wall with or without pv bleed in viable gestation
36
Name 3 types abruptio placenta
- concealed
- revealed
- mixed
37
Name 2 symptoms and 3 signs abruptio placenta
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
Specific Management abruptio placenta?
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
Name 9 maternal complications abruptio placenta
- 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
Define vasa praevia
Rupture of foetal vessels running within membranes, often near cervical os and damaged when membranes rupture
41
Name 3 risk factors vasa praevia
- Placenta praevia
- vilamentous placental insertion
- multiple pregnancy
42
Define uterine rupture
Non - surgical disruption/tear of myometrium with or without serosa of uterus, with or without expulsion of foetus and placenta.
43
Name 4 risk factors uterine rupture
- 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
Name 6 signs of imminent uterine rupture
- 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
Name 8 signs uterine rupture
- 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
Name 5 risk factors uterine atony
- Precipitous/protracted labour
- uterine overdistension
- grand multiparity
- chorioamnionitis
- medications: mgso4, beta agonists, halogenated anaesthetics
47
Diagnosis uterine atony?
Clinical
- soft, boggy
- enlarged above umbilicus
48
Specific treatment uterine atony? (3)
- Uterotonics
- fundal massage
- B lynch suture
49
Name 3 risk factors retained products of conception
- Accessory placental lobe
- abnormal plantation (depth eg accreta / location)
- operative vaginal delivery
50
Name 3 placental attachment disorders
- Placenta accreta (placental villi invade surface of myometrium)
- increta (extend into myometrium)
- percreta (through myometrium into serosa)
51
Name 8 ultrasound features of morbidly adherent placenta
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
Dose ergometrine
0,5 mg IM, repeat X1 if needed
! Contraindicated in cardiac patients
53
Dose misoprostol for PPH
400 - 600 ug (2-3 tabs) Pr
54
Classification of abruptio placenta?
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
