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Y4R2 - Obstetrics I 🤰 > L11: Antepartum Hemorrhage > Flashcards

L11: Antepartum Hemorrhage Flashcards

1
Q

Def of Antepartum Hemorrhage

A

Bleeding in or from genital tract from 20 weeks gestation (28 weeks previously) till birth (including 1st & 2nd stages of labor).

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2
Q

Etiology & DDx of Antepartum Hemorrhage

A
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3
Q

Def of Placenta Previa

A

Placenta is partially or totally implanted in LUS after fetal viability (≥ 20 weeks).

Before 20 weeks, it is termed low lying placenta.

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4
Q

Incidence of Placenta Previa

A
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5
Q

Etiology of Placenta Previa

A
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6
Q

RF for Placenta Previa

A
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7
Q

RF for Placenta Previa

  • Age
A

Old age (9 fold increase in women > 40 years)

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8
Q

RF for Placenta Previa

  • Parity
A

More common in multiparas

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8
Q

RF for Placenta Previa

  • Previous Uterine Scar
A

C.S (4 folds increase) / myomectomy / deep curettage

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9
Q

RF for Placenta Previa

  • Previous Placenta Previa
A

Commonest risk factor

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10
Q

RF for Placenta Previa

  • Commonest RF
A

Previous placenta previa

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11
Q

Classification of Placenta Previa

A
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12
Q

Pathophysiology of Placenta Previa

  • During 3rd trimester, LUS progressively enlarges but inelastic placenta can’t stretch to accommodate this enlargement → shearing action () placenta & LUS → inevitable separation of part of placenta → unavoidable bleeding.
A

…

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13
Q

Pathophysiology of Placenta Previa

  • Separation is aggravated during labor by progressive taking up of LUS combined è downward advancement of lower pole of intact sac of membranes making double shearing mechanism on placenta.
A

…

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14
Q

Pathophysiology of Placenta Previa

  • No mechanism to stop bleeding because:
A
  1. LUS is non retractile.
  2. Muscle fibers of LUS are atonic è absence of decussating muscle layer.
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15
Q

Pathophysiology of Placenta Previa

  • Source of Bleeding
A

Maternal blood.

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16
Q

Pathophysiology of Placenta Previa

A
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16
Q

Pathophysiology of Placenta Previa

  • Amount of Bleeding
A

1st attack is variable but recurrent attack is dangerous.

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17
Q

Complications of Placenta Previa

A

Maternal & fetal

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18
Q

Maternal Complications of Placenta Previa

  • During Pregnancy
A
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19
Q

Maternal Complications of Placenta Previa

A
  • During Pregnancy
  • During Labor
  • During Puerperium
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20
Q

Maternal Complications of Placenta Previa

  • During labor
A
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21
Q

Maternal Complications of Placenta Previa

  • During Puerperium
A
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22
Q

Maternal Complications of Placenta Previa

  • During Puerperium (PPH)
A
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23
Q

Maternal Complications of Placenta Previa

  • During Puerperium (Puerperal Sepsis)
A
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24
Q

Fetal Complications of Placenta Previa

A
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25
Q

Dx of Placenta Previa

  • Hx
A
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26
Q

Dx of Placenta Previa

  • Ex
A
  • General, Abdominal, Speculum & Local
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27
Q

Dx of Placenta Previa

  • Abdominal Ex
A
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28
Q

Dx of Placenta Previa

  • general Ex
A

Signs of hypovolemic shock (according to amount of blood loss)

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29
Q

Dx of Placenta Previa

  • Local Ex
A
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30
Q

Dx of Placenta Previa

  • Speculum
A

For exclusion of local gynecological causes of bleeding.

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31
Q

Indications of Local Ex in Placenta Previa

A

It has no role in modern obstetrics however, it can be done only when active treatment is indicated.

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32
Q

Precautions of Local Ex in Placenta Previa

A

→ Done in operating room under complete aseptic precautions & everything is ready for immediate CS if needed.

→ Cross matched blood should be available for transfusion if
needed.

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33
Q

Information gained in Local Ex in Placenta Previa

A

→ Amount of bleeding.
→ Degree of cervical effacement & dilatation.
→ Relation of placental edge to internal os.
→ Condition of membranes.
→ Presentation & Pelvic capacity.

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34
Q

Disadvantages of Local Ex in Placenta Previa

A

→ May initiate severe attack of bleeding.
→ False diagnosis (mistaken for blood clots).

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35
Q

Investigations for Placenta Previa

A
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36
Q

Main Tool for Dx of Placenta Previa

A

US

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37
Q

advantages of US in Dx of Placenta Previa

A

Safe, simple, rapid & accurate

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38
Q

Types of US in Dx of Placenta Previa

A
  • TAS.
  • TVS (more accurate but risky).
  • Transperineal ultrasound.
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39
Q

US in Dx of Placenta Previa

  • value
A
  • Diagnosis of placenta previa & determination of its type.
  • Determination of fetal age, viability, size, presentation & position.
  • Exclusion of multifetal pregnancy & congenital anomalies.
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40
Q

Dx of Placenta Previa

  • MRI
A

Safe but expensive.

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41
Q

Dx of Placenta Previa

  • Others
A

For maternal & fetal evaluation.

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42
Q

TTT of Placenta Previa Depend on …..

A
  1. Severity of bleeding.
  2. Patient is in labor or not.
  3. Type of placenta previa.
  4. Fetal are & maturity.
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43
Q

Plan of TTT in Placenta Previa

  • Severe bleeding
A

Resuscitation then immediate CS.

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44
Q

Plan of TTT in Placenta Previa

  • Mild to Moderate Bleeding
A

in Labor or not?

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45
Q

Plan of TTT in Placenta Previa

  • Mild to Moderate Bleeding while Patient is in labor
A
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46
Q

Plan of TTT in Placenta Previa

  • Mild to Moderate Bleeding while patient is NOT in labor
A
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47
Q

Lines of TTT of in Placenta Previa

A
  • 1st aid measures & resuscitation
  • Expectant treatment
  • Termination of pregnancy
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48
Q

Lines of TTT of in Placenta Previa

  • 1st Aid measures & resucitation
A
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49
Q

1st Aid measures & resucitation in Placenta Previa

  • Antishock Measures
A

a) Cross matched fresh blood transfusion.

b) IV fluids (crystalloid solutions as Ringer’s lactate & saline).

c) Corticosteroids.

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50
Q

1st Aid measures & resucitation in Placenta Previa

  • IV lines
A

Insert 2 large wide pore cannulas & CVP catheter.

51
Q

1st Aid measures & resucitation in Placenta Previa

  • Labs
A

CBC, coagulation profile, arterial blood gases & serum creatinine.

52
Q

1st Aid measures & resucitation in Placenta Previa

  • Confirmation of diagnosis & detection of type of placenta previa
A

By ultrasound & double setup vaginal examination.

53
Q

1st Aid measures & resucitation in Placenta Previa

  • Evaluation of Fetus
A

Living or dead, age, maturity & wellbeing.

54
Q

Expectant TTT in Placenta Previa

  • Aim
A

delay TOP till fetus is mature enough (till end of 37* week).

55
Q

Expectant TTT in Placenta Previa

  • Prerequiseties
A
56
Q

Expectant TTT in Placenta Previa

  • Measures
A
57
Q

TOP in Placenta Previa

  • Indications
A
  1. Severe bleeding.
  2. Patient is in labor.
  3. Mature fetus (patient 1st seen after 37 weeks).
58
Q

Methods of TOP in Placenta Previa

A
  • CS
  • Vaginal
59
Q

Indications of CS in Placenta Previa

A
60
Q

Why is Placenta previa type Il posterior (More dangerous)?

A
61
Q

Type of CS in Placenta Previa

A

LSCS (allows better control of bleeding).

62
Q

CS in Placenta Previa

  • fetal Approach
A
63
Q

CS in Placenta Previa

  • Precautions
A
  1. Operation should be managed by senior obstetrician & anesthetist.
  2. Care from PPH.
64
Q

Vaginal delivery in Placenta Previa

  • Prerequisities
A
65
Q

Vaginal delivery in Placenta Previa

  • Precautions
A
  1. Continuous fetal & maternal monitoring.
  2. Care from PPH.
66
Q

Vaginal delivery in Placenta Previa

  • Old Vaginal Methods
A

Used only in dead or hopeless fetus è severe bleeding:

  1. Willett’s scalp forceps.
  2. Bipolar podalic version & bringing down leg to compress placenta by 1/2 breech.
67
Q

Another name of Placental Abruption

A

Accidental Hemorrhage

68
Q

def of Placental Abruption

A

APH due to separation of normally implanted placenta before 3rd stage of labor.

69
Q

Incidence of Placental Abruption

A

1% of deliveries.

70
Q

Etiology of Placental Abruption

A
71
Q

Compare between HTN Placental Abruption & Non-HTN Placental Abruption in terms of:

  • Historic Name
  • Incidence
  • Parity
  • Causes
A
72
Q

Causes of Non-HTN Placental Abruption

A
73
Q

Pathogenesis of HTN Placental Abruption

A
74
Q

Pathogenesis of Non-HTN Placental Abruption

A
75
Q

Classification (Types) of Placental Abruption

A
  • Clinical & Severity
76
Q

Classification (Types) of Placental Abruption

  • Clinically
A

1) Revealed accidental Hge
2) Concealed accidental Hge
3) Mixed (combined) accidental Hge

77
Q

Classification (Types) of Placental Abruption

  • Severity (Sher’s)
A
78
Q

Sher’s Classification Placental Abruption

  • Grade 0
A

Small retroplacental hematoma discovered on maternal surface of placenta after delivery (no APH)

79
Q

Sher’s Classification Placental Abruption

  • Grade I
A

Mild revealed or mixed Hge + uterine tetany & tenderness
+ no fetal distress + no maternal shock.

80
Q

Sher’s Classification Placental Abruption

  • Grade II
A

Moderate revealed or mixed Hge + uterine tetany & tenderness + fetal distress + no maternal shock.

81
Q

Sher’s Classification Placental Abruption

  • Grade III
A
82
Q

Assessment of severity of Bleeding in Placental Abruption

A
83
Q

Complications of Placental Abruption

A

Fetal & Maternal

84
Q

Fetal Complications of Placental Abruption

A
85
Q

Maternal Complications of Placental Abruption

A
86
Q

Maternal Complications of Placental Abruption

  • Shock
A

Partly hypovolemic (Hge) & partly neurogenic (ry to peritoneal irritation).

87
Q

Maternal Complications of Placental Abruption

  • Renal failure
A
88
Q

Maternal Complications of Placental Abruption

  • Sheehan Syndrome
A

Due to ischemic necrosis of anterior pituitary.

89
Q

Maternal Complications of Placental Abruption

  • DIC
A
90
Q

Maternal Complications of Placental Abruption

  • Couvelaire uterus (uteroplacental apoplexy)
A
91
Q

Maternal Complications of Placental Abruption

  • PPH
A
92
Q

Compare between Revealed PA - Concealed PA - Mixed PA in terms of:

  • Incidence
  • Placental Separation
  • Pathway of Blood
  • Bleeding
  • Symptoms (Vaginal Bleeding, Pain, Cause)
  • General Signs (Shock, Cause)
  • Abdominal Signs (Uterus, Fetal Parts, FHS)
  • Local Signs (Vaginal Bleeding, Placenta, Membranes)
A
93
Q

Compare between Revealed PA - Concealed PA - Mised PA in terms of:

  • Incidence
A
94
Q

Compare between Revealed PA - Concealed PA - Mised PA in terms of:

  • palcental Separartion
A
95
Q

Compare between Revealed PA - Concealed PA - Mised PA in terms of:

  • Blood Pathway
A
96
Q

Compare between Revealed PA - Concealed PA - Mised PA in terms of:

  • Bleeding
A
97
Q

Compare between Revealed PA - Concealed PA - Mised PA in terms of:

  • Symptoms
A
98
Q

Compare between Revealed PA - Concealed PA - Mised PA in terms of:

  • General Signs
A
99
Q

Compare between Revealed PA - Concealed PA - Mised PA in terms of:

  • Abdominal Signs
A
100
Q

Compare between Revealed PA - Concealed PA - Mised PA in terms of:

  • Local Signs
A
101
Q

Investigations in Placental Abruption

A
  • US
  • Labs
  • Others
102
Q

US in Placental Abruption

A

For exclusion of placenta previa, detection of retroplacental hematoma & determination of fetal age, viability, size, presentation & position.

103
Q

Labs in Placental Abruption

A

CBC, coagulation profile & renal function tests.

104
Q

Other INVx in Placental Abruption

A

For detection of the cause (as PET) & for maternal & fetal evaluation

105
Q

TTT of Placental Abruption Depends on …..

A
  1. Fetus is living or dead.
  2. Severity of bleeding.
  3. Fetal wellbeing, age & maturity (if fetus is living).
  4. Patient is in labor or not.
105
Q

Bleeding in concealed types is Concealed due to:

A
105
Q

DDx of Placental Abruption

A
106
Q

Plan of TTT of Placental Abruption

  • Dead Fetus
A

Resuscitation then vaginal delivery

107
Q

Plan of TTT of Placental Abruption

  • Living Fetus
A
108
Q

Plan of TTT of Placental Abruption

  • Living fetus with severe abruption
A

Resuscitation then immediate CS.

109
Q

Plan of TTT of Placental Abruption

  • Living fetus with non severe abruption
A
110
Q

Lines of TTT of Placental Abruption

A
  • 1st Aid Measures
  • Expectant TTT
  • TOP
  • TTT of Cause
  • TTT of Complications
111
Q

Lines of TTT of Placental Abruption

  • 1st Aid Measures
A

As in placenta previa + Exclusion of placenta previa & detection of retroplacental hematoma.

112
Q

Lines of TTT of Placental Abruption

  • Expectant TTT
A

As in placenta previa.

113
Q

Lines of TTT of Placental Abruption

  • TOP
A

Vasginal & CS

114
Q

Indications of TOP in Placental Abruption

A

Usually, pregnancy is terminated in all cases except cases fulfilling criteria for expectant treatment

115
Q

Methods of TOP in Placental Abruption

A

Vaginal & CS

116
Q

Indications of Vaginal Delivery in Placental Abruption

A
117
Q

Method of Vaginal Delivery in Placental Abruption

A

AROM + Oxytocin drip or PGs according to situation.

118
Q

Value of AROM in Vaginal Delivery in Placental Abruption

A
119
Q

Advantages of Vaginal Delivery over CS in Placental Abruption

A
  1. Less blood loss.
  2. Avoidance of coagulopathy during CS (in vaginal delivery, bleeding stops by uterine contractions while in CS, bleeding stops by coagulation mechanism which is deficient).
120
Q

Vaginal Delivery in Placental Abruption

  • Precautions
A
  1. Abdominal binder.
  2. Continuous fetal & maternal monitoring.
  3. Care from PPH.
121
Q

CS in Placental Abruption

  • Indications
A
  1. Severe bleeding.
  2. Deteriorating maternal condition.
  3. Living fetus (rarely found) è fetal distress.
  4. Failed vaginal delivery (for 8 hours).
  5. Other indications for CS.
122
Q

CS in Placental Abruption

  • Precautions
A
123
Q

Lines of TTT of Placental Abruption

  • TTT of the Cause
A

TTT of preeclampsia.

124
Q

Lines of TTT of Placental Abruption

  • TTT of Complications
A

TTT of renal failure & DIC.

125
Q

Compare between placenta previa centralis & placental abruption

A

OSCE

Y4R2 - Obstetrics I 🤰 (52 decks)

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