HAEMORRHAGE Flashcards
Define antepartum haemorrhage
Bleeding from or into genital tract from 24 weeks gestation (viability) and prior to birth of baby (until first and second stage labour)
Name 4 main causes antepartum haemorrhage
- Abruptio placenta
- placenta praevia / vasa praevia
- local causes: lacerations, infection (cervicitis,vaginitis), cancer, trauma, warts, ulcers…
- APH of unknown origin
( Uterine rupture )
Name 8 risk factors antepartum haemorrhage caused by abruptio placenta
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
Name 8 causes / risk factors antepartum haemorrhage caused by placenta praevia
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
Cause of tense/ woody uterus?
Significant abruption
When should digital examination be avoided?
Placenta praevia
Premature rupture of membranes
Management antepartum haemorrhage? (9)
- 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
Define primary postpartum haemorrhage
First 24 hours after delivery
Blood loss > 500 ml after vaginal, 1000 ml after c/S
Define secondary postpartum haemorrhage
24 hours - 6 weeks after delivery
> 500 ml vaginal, 1000 c/s
Define persistent postpartum haemorrhage
Active bleedin > 1000 ml within 24 hours following birth that continues despite use initial measures including uterotonics and massage
Prevention postpartum haemorrhage (6)
- 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
Name 5 causes postpartum haemorrhage
4 Ts
- tone: uterine atony
- Trauma to genital tract
- thrombosis: coagulation defects
- tissue: retained products of conception
- uterine inversion
Stepwise Medical treatment uterine atony? (7)
- 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
Approach to postpartum haemorrhage after vaginal delivery? (10)
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
Management PPH after vaginal delivery + resus, with soft uterus? (5)
→ 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)
Management ongoing PPH after vaginal delivery , when resuscitation has been performed and placenta and uterus examined and managed? (7)
- 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
Approach to management post partum haemorrhage after ceserean section (6)
- 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:
Classify perineal tears (6)
- 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
Define buttonhole tear. Complication?
Involve only anal mucosa with intact anal sphincter complex, must be documented as separate entity to perineal tear.
Can → anovaginal fistula
How repair first and second degree perineal tear?
Bedside sutures
How repair third and fourth degree perineal tear? (3)
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
Post op and repair management perineal tears? (5)
- 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
Define acute uterine inversion
Collapse uterine fundus into endometrial cavity
Name 4 risk factors acute uterine inversion
- Excess cord traction
- fundal pressure
- fundal cord insertion
- abnormal plantation
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
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
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
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
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
Define placenta praevia
Implantation of placenta partially/completely in lower segment uterus within 2 cm of cervix
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
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
Name 2 foetal complications of placenta praevia
- Prematurity
- foetal insult → hie, cp, intrauterine foetal demise
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
Define abruptio placenta
Premature separation placenta from uterine wall with or without pv bleed in viable gestation
Name 3 types abruptio placenta
- concealed
- revealed
- mixed
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
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
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
Define vasa praevia
Rupture of foetal vessels running within membranes, often near cervical os and damaged when membranes rupture
Name 3 risk factors vasa praevia
- Placenta praevia
- vilamentous placental insertion
- multiple pregnancy
Define uterine rupture
Non - surgical disruption/tear of myometrium with or without serosa of uterus, with or without expulsion of foetus and placenta.
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
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
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
Name 5 risk factors uterine atony
- Precipitous/protracted labour
- uterine overdistension
- grand multiparity
- chorioamnionitis
- medications: mgso4, beta agonists, halogenated anaesthetics
Diagnosis uterine atony?
Clinical
- soft, boggy
- enlarged above umbilicus
Specific treatment uterine atony? (3)
- Uterotonics
- fundal massage
- B lynch suture
Name 3 risk factors retained products of conception
- Accessory placental lobe
- abnormal plantation (depth eg accreta / location)
- operative vaginal delivery
Name 3 placental attachment disorders
- Placenta accreta (placental villi invade surface of myometrium)
- increta (extend into myometrium)
- percreta (through myometrium into serosa)
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
Dose ergometrine
0,5 mg IM, repeat X1 if needed
! Contraindicated in cardiac patients
Dose misoprostol for PPH
400 - 600 ug (2-3 tabs) Pr
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
