Haemorrhage Flashcards
Main causes of APH
Placental abruption
Placenta praevia
Vasa praevia
Uterine rupture
Describe types of placental abruption
Revealed - edge of placenta separates from uterine wall resulting in PV bleeding
Concealed - centre of placenta separates from uterine wall. Can cause DIC
Clinical features of placental abruption
Tense or tender abdomen
Tachycardia
+/- PV bleeding
CTG heart rate abnormality
Grades of placenta praevia
1: <3cm from os (<5cm on US)
2: touching the os
3. Covering half the os
4. Covering the entire os
Diagnosis of placenta praevia
USS
What is vasa praevia
Cord branches before entering placenta
Blood vessels may be close to os and can be damaged in examination
What is placenta accreta
Placenta invades myometrium (can invade further)
Often through a C section scar
Management of APH due to placental abruption
A-E assessment
Stabilise mother
Blood test: cross match 4-6 units, coag screen, Hb and platelets
Continuous CTG monitoring
Deliver asap:
- If fully dilated, vaginal delivery may be faster
- Otherwise a C section
Management of PPH
A-E assessment Lie patient flat Bimanual fundal massage Fluid resuscitate in meantime but transfuse asap Blood test: Hb, coag screen, cross match 4-6 units Catheterise Drugs If drugs fail, theatre
Drug management of PPH
- IV syntocinon
- Ergometrin
- Haemibate 250mg IM (a PG)
Surgical management of PPH
- Bakri balloon insertion
- B lynch suture
- Uterine artery ligation
- Hysterectomy
Causes of PPH
Atonic uterus e.g prolonged labour Retained placenta/accreta Trauma DIC APH
Weeks of APH and PPH
APH from week 24 to 2nd stage of labour
PPH from 2nd stage of labour onwards
Risk factors for placental abruption
Multiple pregnancy Previous history Polyhydramnios ECV Preeclampsia Previous C/S >41 weeks Cocaine
Risk factors for placenta praevia
Previous history Previous C/S Multiparous Previous miscarriage IVF
Management of placenta praevia
US at 32 weeks
Plan C/S if placental edge <2cm from os
Admit from week 34 (risk of cord prolapse and abruption)
Monitor blood loss (may need transfusion)
Avoid intercourse if grade 2-4
Management of placenta accreta
C/S to delivery baby followed by total hysterectomy
May need urology, bowel and vascular surgeons present
Management of vasa praevia
Emergency C/S asap if presenting with APH with rupture of membranes
If detected antenally prepare for elective C/S and avoid vaginal examinations
Risk factors for vasa praevia
IVF
Placenta praevia
Multiple pregnancy
Primary vs secondary PPH
Primary within 24 hours of delivery
Secondary 24 hours after delivery to 6 weeks postpartum
Minor vs major PPH
Minor 500-1000ml
Major >1000ml
Risk factors for PPH
APH in current pregnancy Prolonged labour Multiple pregnancy Preeclampsia Maternal obesity Multiparous Previous history Maternal age >40 Maternal obesity
What’s the most common cause of post partum haemorrhage
Uterine atony
Describe Sheehans syndrome
Complication of major PPH where there is pituitary ischaemia
Cause of secondary amenorrhoea and infertility
What is an episiotomy
Mediolateral incision from the vagina to increase the opening for the fetal head to be delivered
Prevents posterior tearing = faecal incontinence and fistula formation
Grades of perineal tears
1- mucosa
2- perineal muscles
3- anal sphincter muscles
4- extends to anus (anal epithelium breached)
Management of grade 3-4 perineal tear
Suture under LA
Analgesic suppository
Stool softeners
Pelvic floor exercises
