High risk pregnancy: Maternal medical condition( e.g. diabetes, obesity) Flashcards
Definiton of antepartum bleeding
Bleeding of the genital tract, occurring from 24 weeks of gestation until birth.
Aetiology of APH
- placental abruption (30%)
- placenta praevia (20%)
- uterine rupture (rare) • vasa praevia (rare)
- Other causes include cervical lesions (such as polyps or ectropion), infection, trauma or malignancy.
Definiton and aetiology of Placenta Praevia
• Placenta praevia is a placenta that is partially or wholly implanted into the lower uterine segment.
• 0.4% pregnancies at term
• 20 weeks- low placenta in many pregnancies but moves
upwards- 5% of pregnancies
Aetiology-
• More common in twins • High parity
• Advanced maternal age
Classification of placenta previa
- Marginal (previously types 1-2) - placenta in lower segment not over the os
- Major( previously types 3-4)- placenta completely or partially covering the os
Complications placenta previa
- Needs caesarean section as obstructs engagement of head
- Haemorrhage-severe bleeding during and after delivery
- If palcenta implants into previous caesarean scar and myometrium- placenta accreta
- If penetrates though uterine wall into surrounding structures- placenta percreta
Clinical features: placenta previa
- History- intermittent painless bleeding in pregnancy
- Examination- breech/transverse lie are common
- Vaginal examination can provoke massive bleeding, hence avoided if placenta previa is suspected
Investigations for placenta previa
Ultrasound- used to locate the placenta
If low lying placenta is found at 20weeks – scan id repeated at 32 weeks
Placenta <2cm from the internal os at term is placenta previa
If placenta is anterior with pre LSCS , 3D ultrasound or MRI is used to diagnose accreta
- Full blood count
- Cross match 6 units of blood • Clotting profile
- CTG (Cardiotocography)
placenta previa management
- Admit
- Intravenous access
- Steroids if <34 weeks
- Blood kept available and ready • Anti D if rhesus negative
Placenta accreta care bundle
- Consultant obstetrician planned and directly supervising delivery
- consultant anaesthetist planned and directly supervising anaesthetic at delivery
- blood and blood products available
- multidisciplinary involvement in pre-op planning
- discussion and consent includes possible interventions (such as hysterectomy, leaving the placenta in place,cell salvage and intervention radiology)
Define Placental abruption
- When part or all of the placenta separates before delivery of the fetus
- 1% of pregnancies
- Considerable maternal bleeding occurs
- Fetal distress
implications of Placental abruption
fetal distress
intrauterine death
disseminated intravascular coagulopathy
Aetiology of placenta abruption
- IUGR
- Pre-eclampsia
- Autoimmune disease
- Smoking
- Cocaine abuse
- Previous history of abruption • Multiple pregnancy
- Multiparity
- Trauma
- Pre-existing hypertension
Clinical features of placental abruption
- Painful bleeding
- Pain is due to blood behind placenta • Concealed- when bleeding is not seen • Revealed- bleeding is evident Examination-
- Tachycardia
- Hypotension
- Uterus is tender
- FHS- abnormal or absent
- Uterus can be woody hard
Investigations of placental abruption
- Diagnosis is made on clinical grounds
- CTG -cardiotocography for fetal well being • FBC
- Clotting profile
- Cross match blood
- Catheter- hourly urine output
- Urea and creatinine
Management of placental abruption
- Admission
- IV cannula
- IV Fluids / blood and blood products • Steroids if gestation<34 weeks
- Analgesia
- Anti D if rhesus negative • Early delivery
Delivery in placental abruption
- Mother is stabilised first
- Depends on fetal state and gestation
- If fetal distress category one caesarean section
- If no fetal distress labour can be induced with amniotomy
Differentiation between placental abruption and placenta previa
Abruption
painful bleeding, may be absent or concealed, severed tenderness woody hard uterus, fetes may be dead or distressed, ultrasound often normal placenta not low.
Placenta previa - no pain, red and profuse blood, tenderness is rare, placenta low son ultrasound
what is Vasa previa?
- When fetal blood vessels runs in the membranes in front of the presenting part
- 1% of pregnancies
- Massive fetal bleeding occurs if these ruptures
- Usually severe fetal distress
Other causes of bleeding apart from previa and abruption
- Uterine rupture
* Cervical carcinoma /polyp/ectropion/tears
