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Reproductive and Neonatal Health (RNH) > Late Pregnancy > Flashcards

Late Pregnancy Flashcards

1
Q

Outline some differentials for LATE and EARLY pregnancy bleeding.

A

EARLY PREGNANCY BLEEDING
✔️ implantation bleeding
✔️ spontaneous abortion / miscarriage
✔️ ruptured ectopic pregnancy

LATE PREGNANCY BLEEDING
✔️ placenta previa
✔️ placental abruption
✔️ uterine rupture

Non-obstetric causes (can occur in both) 
✔️ cervicitis 
✔️ cervical cancer
✔️ polyps
✔️ trauma / lacerations
✔️ haemorrhoids 
✔️ haematuria
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2
Q

Define PLACENTA PREVIA. What are the four types of placenta prevue?

A

Placenta previa is an obstetric complication in which the placenta implants over the internal os of the cervix.

There are four types:

  1. complete placenta previa
  2. partial placenta previa
  3. marginal placenta previa
  4. low-lying placenta

6% of women have a low-lying placenta at the 18-20 week morphology scan; 90% of these resolve spontaneously due to placental migration.

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3
Q

What are some risk factors for placenta previa?

A 
✔️ previous placenta previa
✔️ previous C/S (promotes scar tissue)
✔️ previous abdominal / pelvic surgery (promotes scar tissue)
✔️ increasing maternal age
✔️ previous PID
✔️ multiple gestation
✔️ maternal smoking
✔️ erythroblastic diease
✔️ multi-parity
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4
Q

Describe the clinical presentation of placenta previa.

A

Asymptomatic - diagnosed on USS at 18 to 20 weeks

Symptomatic - profuse, bright red, painless PV bleeding in the 2nd or 3rd trimester

Speculum exam reveals “spongy” uterus

Do NOT perform a bimanual examination due to risk of separating the placenta from surrounding structures.

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5
Q

What is the management of placenta previa?

A

ALL PATIENTS WITH PLACENTA PREVIA MUST HAVE ELECTIVE C/S.

If NOT picked up and present in labour:

  1. Primary survey (ABCDE)
  2. Collect appropriate bloods (FBC, WCC, UECs, eLFTs, coags, cross match, G+H)
  3. Cross match 6 x units packed red blood cells
  4. Plan for pre-term delivery –> corticosteroids if 24 to 36 weeks, magnesium sulphate if 24 to 24 weeks
  5. Emergency C/S
  6. Counsel on risk of hysterectomy
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6
Q

Define PLACENTAL ABRUPTION.

A

Placental abruption is an obstetric emergency in which the placenta separates from the uterine walls. This results in significant haemorrhage between the uterus and the placenta.

DIC is a major complication.

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7
Q

What are some risk factors for placental abruption?

A 
✔️ previous placental abruption
✔️ increasing maternal age (> 40 years)
✔️ BMI < 18 or > 35
✔️ uncontrolled HTN
✔️ maternal smoking, methamphetamine or drug use
✔️ multiple gestations
✔️ polyhydroamniosis 
✔️ vascular disorders

Placental abruption may occur spontaneously, or may be precipitated by:
✔️ trauma
✔️ MVA
✔️ domestic violence

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8
Q

Describe the clinical presentation of placental abruption.

A

✔️ acute, severe abdominal pain with PV bleeding
✔️ hypertonic uterus on speculum exam
✔️ “woody” abdomen

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9
Q

Outline the management of placental abruption.

A
  1. Primary survey (ABCDE)
  2. Collect appropriate bloods (FBC, UECs, eLFTs, Coags, G+H, cross match, D-Dimer and Fibrinogen)
  3. Cross match 4 to 6 units of blood
  4. Prepare for early delivery
    ✔️ maternal steroids
    ✔️ magnesium sulfate
    ✔️ tocolysis (some consider a contraindication)
  5. Delivery if:
    ✔️ foetal distress
    ✔️ irreversible labour
    ✔️ life-threatening haemorrhage
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10
Q

What are some complications of PLACENTAL ABRUPTION?

A

✔️ DIC
✔️ hypovolemic shock
✔️ hysterectomy
✔️ death (maternal and foetal)

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11
Q

Define UTERINE RUPTURE.

A

Uterine rupture is an obstetric emergency in which the uterine tissue tears, most commonly in labour.

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12
Q

What are some risk factors for UTERINE RUPTURE?

A

Most common risk factors:
✔️ previous C/S
✔️ previous abdominal / pelvic surgery
✔️ oxytocin use during pregnancy

Other risk factors: 
✔️ grand multi-parity
✔️ abnormal foetal lie
✔️ macrosomnia 
✔️ external cephalic version
✔️ trauma
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13
Q

Describe the clinical presentation of UTERINE RUPTURE.

A

✔️ acute onset, severe, 10/10 abdominal pain
✔️ PV bleeding
✔️ foetal demise
✔️ regression of the presenting part

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14
Q

What is the management of UTERINE RUPTURE?

A

Emergency C/S

Hysterectomy

Complications:
✔️ hysterectomy
✔️ DIC and consumptive coagulopathy
✔️ maternal and foetal death

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15
Q

Define ANTEPARTUM Haemorrhage.

A

Antepartum haemorrhage is bleeding that occurs > 20 weeks gestation.

Any bleeding in pregnancy is ABNORMAL and requires immediate investigation with: 
✔️ bimanual and speculum examination
✔️ foetal HR monitoring (CTG)
✔️ maternal HR and BP monitoring 
✔️ transvaginal USS
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16
Q

Define POST PARTUM HAEMORRAGE.

A

PPH is defined as > 500mL blood loss (vaginal delivery) or > 1,000 mL blood loss (C/S delivery).

17
Q

What are the four causes of PPH?

A
  1. tone (70%)
  2. trauma (20%)
  3. tissue (10%)
  4. thrombin (1%)
18
Q

What are some causes of PPH that fit under the category of TONE?

A 
OVER DISTENDED UTERUS
✔️ polyhydroamniosis 
✔️ multiple gestations
✔️ macrosomnia 
✔️ uterine inversion

FATIGUED UTERUS
✔️ prolonged 2nd stage of labour
✔️ rapid labour
✔️ excessive oxytocin use

19
Q

What are some causes of PPH that fit under the category of TRAUMA?

A 
✔️ episiotomy 
✔️ instrumental delivery (particularly forceps delivery)
✔️ prolonged 2nd stage of labour
✔️ uterine rupture 
✔️ emergency C/S
20
Q

What are some causes of PPH that fit under the category TISSUE?

A

✔️ placenta previa
✔️ placenta acreta
✔️ retained products of conception

21
Q

What are some causes of PPH that fit under the category THROMBIN?

A

✔️ DIC
✔️ severe pre-eclampsia or eclampsia (derange LFTs and coags)
✔️ coagulopathies
✔️ iatrogenic causes

22
Q

Describe the management of PPH.

A
  1. Primary survey (ABCDE)
  2. Call a senior / consultant
  3. Ensure IM oxytocin was given in 2nd stage of labour
  4. Give oxytocin 40 units IM
  5. Assess tone of uterus –> massage if atonic
  6. Assess for visible trauma –> ligate if bleeding; do NOT massage if actively bleeding
  7. Assess placenta (in tact and whole) + speculum exam for retained products of conception
  8. Give uterotonic agents:
    ✔️ ergometrine 500microg IM or 250microg 250 IV
    ✔️ misoprostol / prostaglandin analogues
  9. Give tranexemic acid 1g over 10 mins IV
  10. Bimanual compression / tamponade or Bakery Balloon catheter if still bleeding
  11. Give warmed blood products
  12. Reverse coagulopathies (if present)
  13. Send to theatre
23
Q

What are some complications of PPH?

A 
✔️ hypovolemic shock 
✔️ DIC + consumptive coagulatopathy 
✔️ maternal death
✔️ Sheehan's Sydrome
✔️ hysterectomy (definitive management)

Reproductive and Neonatal Health (RNH) (8 decks)

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